Provider Demographics
NPI:1376765222
Name:GREEN, GARY JOEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOEL
Last Name:GREEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 LINDELL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3702
Mailing Address - Country:US
Mailing Address - Phone:314-361-1818
Mailing Address - Fax:314-361-6585
Practice Address - Street 1:4646 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3702
Practice Address - Country:US
Practice Address - Phone:314-361-1818
Practice Address - Fax:314-361-6585
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0134341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice