Provider Demographics
NPI:1699128728
Name:GREEN DENTAL
Entity type:Organization
Organization Name:GREEN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRISH
Authorized Official - Middle Name:
Authorized Official - Last Name:NIERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-662-8815
Mailing Address - Street 1:1008 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-1823
Mailing Address - Country:US
Mailing Address - Phone:509-662-8815
Mailing Address - Fax:509-667-8725
Practice Address - Street 1:1008 5TH ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-1823
Practice Address - Country:US
Practice Address - Phone:509-662-8815
Practice Address - Fax:509-667-8725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60022722261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60022722OtherDENTAL LICENSE