Provider Demographics
NPI:1417038712
Name:GREEN, AMBER JENKINS (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMBER
Middle Name:JENKINS
Last Name:GREEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:AMBER
Other - Middle Name:PAULETTE
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:8200 MALL PKWY
Mailing Address - Street 2:SUITE #155
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6983
Mailing Address - Country:US
Mailing Address - Phone:770-484-4051
Mailing Address - Fax:
Practice Address - Street 1:8200 MALL PKWY STE 155
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-6985
Practice Address - Country:US
Practice Address - Phone:770-484-4051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0124191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000945843DMedicaid