Healthcare Provider Details

I. General information

NPI: 1750531414
Provider Name (Legal Business Name): JOHN GREEN II D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US ARMY DENTAC BAVARIA UNIT 28038
APO AE
09112
US

IV. Provider business mailing address

CMR 411 BOX 6741
APO AE
09112-0068
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN013783
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: