Provider Demographics
NPI:1235190877
Name:GREEN, AMY E (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:E
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 1:8905 TWO NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6367
Mailing Address - Country:US
Mailing Address - Phone:803-788-9593
Mailing Address - Fax:803-788-3123
Practice Address - Street 1:8905 TWO NOTCH RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6367
Practice Address - Country:US
Practice Address - Phone:803-788-9593
Practice Address - Fax:803-788-3123
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31611223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9724Medicaid
SCZX3161Medicaid