Provider Demographics
NPI:1144221086
Name:GREEN, LAWANA J (DMD)
Entity Type:Individual
Prefix:
First Name:LAWANA
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6350 W A J HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:4330 MAYNARDVILLE HWY
Practice Address - Street 2:
Practice Address - City:MAYNARDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37807-3618
Practice Address - Country:US
Practice Address - Phone:865-992-3849
Practice Address - Fax:865-992-5166
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC70611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice