Provider Demographics
NPI:1164489001
Name:GREEN, JAMES GORDON (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GORDON
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:D4-4
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-3003
Mailing Address - Country:US
Mailing Address - Phone:352-392-4116
Mailing Address - Fax:352-392-3070
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:D4-4
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-5800
Practice Address - Fax:352-392-3070
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDTP 0351223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAG 1132668OtherDEA
FLAG 1132668OtherDEA
FLD 61245Medicare UPIN