Provider Demographics
NPI:1972614717
Name:GREEN, DOUGLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 ASPEN LAKE DR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-3100
Mailing Address - Country:US
Mailing Address - Phone:612-964-9172
Mailing Address - Fax:
Practice Address - Street 1:10729 TOWN SQUARE DR NE
Practice Address - Street 2:#150
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449
Practice Address - Country:US
Practice Address - Phone:763-269-8650
Practice Address - Fax:763-201-3377
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND113701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice