Healthcare Provider Details

I. General information

NPI: 1407460942
Provider Name (Legal Business Name): JACOB ALAN GREENE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S GROVE ST STE 1
PETERSBURG WV
26847-1805
US

IV. Provider business mailing address

PO BOX 97
BAKER WV
26801-0097
US

V. Phone/Fax

Practice location:
  • Phone: 304-257-2451
  • Fax:
Mailing address:
  • Phone: 304-897-5915
  • Fax: 304-897-8472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN016106
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4671
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: