1972584969 NPI number — DR. ANTHONY TREVOR GREEN D. D. S.

Table of content: DR. ANTHONY TREVOR GREEN D. D. S. (NPI 1972584969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972584969 NPI number — DR. ANTHONY TREVOR GREEN D. D. S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
ANTHONY
Provider Middle Name:
TREVOR
Provider Name Prefix Text:
DR.
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:
1972584969
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17836 WEXFORD TER
Provider Second Line Business Mailing Address:
SUITE 2E
Provider Business Mailing Address City Name:
JAMAICA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11432-3024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-739-1300
Provider Business Mailing Address Fax Number:
718-739-0966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17836 WEXFORD TER
Provider Second Line Business Practice Location Address:
SUITE 2E
Provider Business Practice Location Address City Name:
JAMAICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11432-3024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-739-1300
Provider Business Practice Location Address Fax Number:
718-739-0966
Provider Enumeration Date:
11/08/2005

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: 1223S0112X , with the licence number:  0473299 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02166558 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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