Provider Demographics
NPI:1992748529
Name:GREEN, GARY WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:WAYNE
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 1:16133 VENTURA BLVD
Mailing Address - Street 2:SUITE 1040
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2403
Mailing Address - Country:US
Mailing Address - Phone:818-995-0294
Mailing Address - Fax:818-995-7549
Practice Address - Street 1:16133 VENTURA BLVD
Practice Address - Street 2:SUITE 1040
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2403
Practice Address - Country:US
Practice Address - Phone:818-995-0294
Practice Address - Fax:818-995-7549
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA226051223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954297884OtherCORP ID #