Provider Demographics
NPI:1235392283
Name:ANTHONY T.R. GREEN D.D.S.P.C.
Entity Type:Organization
Organization Name:ANTHONY T.R. GREEN D.D.S.P.C.
Other - Org Name:ANTHONY GREEN D.D.S.
Other - Org Type:Other Name
Authorized Official - Title/Position:ORAL SURGEON/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:TR
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDSOMFS
Authorized Official - Phone:718-739-1300
Mailing Address - Street 1:17836 WEXFORD TER
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3024
Mailing Address - Country:US
Mailing Address - Phone:718-739-1300
Mailing Address - Fax:718-739-0966
Practice Address - Street 1:17836 WEXFORD TER
Practice Address - Street 2:SUITE 2E
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3024
Practice Address - Country:US
Practice Address - Phone:718-739-1300
Practice Address - Fax:718-739-0966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02166558Medicaid