Ivan L Green

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

2901009700 Issued in MI

Practice address

19551 E 10 Mile Rd
Roseville, MI 48066-3998

Phone

(586) 775-6770

NPI assigned

Jan 7, 2011

Last updated

Jan 7, 2011By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1294358400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1294358400000",
    "number": "1053615831",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "29961 NORTHBROOK ST",
            "city": "FARMINGTON HILLS",
            "state": "MI",
            "postal_code": "483342328",
            "telephone_number": "248-797-7795"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19551 E 10 MILE RD",
            "city": "ROSEVILLE",
            "state": "MI",
            "postal_code": "480663998",
            "telephone_number": "586-775-6770"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GREEN",
        "first_name": "IVAN",
        "middle_name": "L",
        "name_prefix": "Dr.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2011-01-07",
        "last_updated": "2011-01-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "2901009700",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• General Practice Dentistry in Roseville, MI
• Providers in Roseville, MI by specialty
• General Practice Dentistry in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 7, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.