Basic Information
| Provider Information | |||||||||
| NPI: | 1073053120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | NATHANIEL | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | MSC 06 3500 | ||||||||
| Address2: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059254031 | ||||||||
| FaxNumber: | 5059254030 | ||||||||
| Practice Location | |||||||||
| Address1: | MSC 06 3500 | ||||||||
| Address2: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059254031 | ||||||||
| FaxNumber: | 5059254030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2017 | ||||||||
| LastUpdateDate: | 06/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | DEN-DEN-LIC-15398 | MT | Y | Dental Providers | Dentist | General Practice |
No ID Information.