=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972584969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY TREVOR GREEN D. D. S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2005
-----------------------------------------------------
Last Update Date | 03/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17836 WEXFORD TER SUITE 2E
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432-3024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-739-1300
-----------------------------------------------------
Fax | 718-739-0966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17836 WEXFORD TER SUITE 2E
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432-3024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-739-1300
-----------------------------------------------------
Fax | 718-739-0966
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 0473299
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------