Provider Demographics
NPI:1811484900
Name:GREENE, COLLEEN DAVIS
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:DAVIS
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1827
Mailing Address - Country:US
Mailing Address - Phone:828-288-2425
Mailing Address - Fax:859-288-7510
Practice Address - Street 1:496 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1827
Practice Address - Country:US
Practice Address - Phone:828-288-2425
Practice Address - Fax:859-288-7510
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY111051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program