Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 28930 | CA |
N | 1223P0700X | Prosthodontist | 28930 | CA |
NPI | 1053422162 |
---|---|
Provider Name | Lawrence Kelts Green |
First Address | Fort Benning, GA 31905-5645 |
Second Address | Fort Benning, GA 31905-5645 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 08/07/2007 |