Provider Demographics
NPI:1225013964
Name:GEORGE P. GREEN DMD PA
Entity Type:Organization
Organization Name:GEORGE P. GREEN DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-659-2137
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:TURBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29162-0459
Mailing Address - Country:US
Mailing Address - Phone:843-659-2137
Mailing Address - Fax:843-659-2135
Practice Address - Street 1:1192 POPE ST
Practice Address - Street 2:
Practice Address - City:TURBEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29162-0459
Practice Address - Country:US
Practice Address - Phone:843-659-2137
Practice Address - Fax:843-659-2135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ21067Medicaid