Healthcare Provider Details

I. General information

NPI: 1184790826
Provider Name (Legal Business Name): ROOSEVELY T GREEN JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S GREEN ST
PORTSMOUTH VA
23704
US

IV. Provider business mailing address

600 S GREEN ST
PORTSMOUTH VA
23704
US

V. Phone/Fax

Practice location:
  • Phone: 757-399-3752
  • Fax: 757-399-2854
Mailing address:
  • Phone: 757-399-3752
  • Fax: 757-399-2854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6417VA
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: