Provider Demographics
NPI:1285735530
Name:GREEN, DENNIS M (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:M
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23388 MULHOLLAND DR
Mailing Address - Street 2:MAILSTOP 62
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2733
Mailing Address - Country:US
Mailing Address - Phone:310-996-9355
Mailing Address - Fax:310-312-4913
Practice Address - Street 1:1950 SAWTELLE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7014
Practice Address - Country:US
Practice Address - Phone:310-996-9355
Practice Address - Fax:310-312-4913
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G553530OtherBLUE SHIELD
CAWG55353GMedicare ID - Type Unspecified
CAWG55353JMedicare ID - Type Unspecified
CA00G553530OtherBLUE SHIELD
CAWG55353HMedicare ID - Type Unspecified
F11491Medicare UPIN
CAWG55353IMedicare ID - Type Unspecified