Healthcare Provider Details

I. General information

NPI: 1558314385
Provider Name (Legal Business Name): JOEL D GREEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 W COY SMITH HWY
MOUNT VERNON AL
36560-3201
US

IV. Provider business mailing address

251 N BAYOU ST
MOBILE AL
36603-5827
US

V. Phone/Fax

Practice location:
  • Phone: 251-829-9884
  • Fax: 251-829-9507
Mailing address:
  • Phone: 251-690-8158
  • Fax: 251-544-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberETD0008
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5458C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: