Provider Demographics
NPI:1073583209
Name:GREEN, ADINA SIMONE (DMD)
Entity Type:Individual
Prefix:
First Name:ADINA
Middle Name:SIMONE
Last Name:GREEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ADINA
Other - Middle Name:
Other - Last Name:SIMONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:2001 MARCUS AVE
Mailing Address - Street 2:STE 168 S
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-775-2004
Mailing Address - Fax:516-829-7987
Practice Address - Street 1:2001 MARCUS AVE
Practice Address - Street 2:STE 168 S
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-775-2004
Practice Address - Fax:516-829-7987
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist