Provider Demographics
NPI:1437295284
Name:GREEN, JERRY ALLAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALLAN
Last Name:GREEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:GERALD
Other - Middle Name:ALLAN
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 674
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-0674
Mailing Address - Country:US
Mailing Address - Phone:818-216-9979
Mailing Address - Fax:818-222-9972
Practice Address - Street 1:3932 WILSHIRE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3307
Practice Address - Country:US
Practice Address - Phone:213-386-3336
Practice Address - Fax:213-386-2935
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA178331223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17833OtherDENTAL LICENCE