1558314385 NPI number — MR. JOEL D GREEN D.D.S.

Table of content: MR. JOEL D GREEN D.D.S. (NPI 1558314385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558314385 NPI number — MR. JOEL D GREEN D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
JOEL
Provider Middle Name:
D
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558314385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 N BAYOU ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36603-5827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-690-8158
Provider Business Mailing Address Fax Number:
251-544-2188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 W COY SMITH HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36560-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-829-9884
Provider Business Practice Location Address Fax Number:
251-829-9507
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  ETD0008 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 5458C , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1063439065 . This is a "NPI GROUP PAYEE NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 631400174 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 630000013 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 011846 . This is a "MEDICARE GROUP PAYEE NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009156700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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