Provider Demographics
NPI:1154332153
Name:GREEN, LESLIE J (DMD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:J
Last Name:GREEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 ALLENDALE RD
Mailing Address - Street 2:SUITE 322
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1432
Mailing Address - Country:US
Mailing Address - Phone:610-337-0950
Mailing Address - Fax:610-265-3560
Practice Address - Street 1:491 ALLENDALE RD
Practice Address - Street 2:SUITE 322
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-1432
Practice Address - Country:US
Practice Address - Phone:610-337-0950
Practice Address - Fax:610-265-3560
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018089L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice