Provider Demographics
NPI:1215080734
Name:GREEN COUNTRY DENTURE CENTER
Entity type:Organization
Organization Name:GREEN COUNTRY DENTURE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-331-2221
Mailing Address - Street 1:1824 S.E . WASHINGTON BLVD.
Mailing Address - Street 2:PO BOX 3248
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006
Mailing Address - Country:US
Mailing Address - Phone:918-331-2221
Mailing Address - Fax:918-336-1052
Practice Address - Street 1:1824 S.E . WASHINGTON BLVD.
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006
Practice Address - Country:US
Practice Address - Phone:918-331-2221
Practice Address - Fax:918-336-1052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5431122300000X
OK5779122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty