Provider Demographics
NPI:1104865799
Name:GREEN, ROBERT E (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
Last Name:GREEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 W HULL DR
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-3703
Mailing Address - Country:US
Mailing Address - Phone:740-363-3871
Mailing Address - Fax:740-369-6616
Practice Address - Street 1:133 W HULL DR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-3703
Practice Address - Country:US
Practice Address - Phone:740-363-3871
Practice Address - Fax:740-369-6616
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH192471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice