Healthcare Provider Details

I. General information

NPI: 1609268788
Provider Name (Legal Business Name): DALLAS GREEN DMS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3661 S MIAMI AVE STE 806
MIAMI FL
33133-4223
US

IV. Provider business mailing address

6255 W SUNSET BLVD FL 21
LOS ANGELES CA
90028-7422
US

V. Phone/Fax

Practice location:
  • Phone: 786-497-4000
  • Fax: 305-854-0111
Mailing address:
  • Phone: 323-860-5200
  • Fax: 323-467-7119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9108459
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: