Healthcare Provider Details

I. General information

NPI: 1235190877
Provider Name (Legal Business Name): AMY E. GREEN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8905 TWO NOTCH RD
COLUMBIA SC
29223-6367
US

IV. Provider business mailing address

8905 TWO NOTCH RD
COLUMBIA SC
29223-6367
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-9593
  • Fax: 803-788-3123
Mailing address:
  • Phone: 803-788-9593
  • Fax: 803-788-3123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3161
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: