Provider Demographics
NPI:1437764180
Name:JOHN O. GREEN, II, DDS, PC
Entity Type:Organization
Organization Name:JOHN O. GREEN, II, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:O
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-489-1450
Mailing Address - Street 1:6126 PRESTLEY MILL RD STE J
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6126 PRESTLEY MILL RD STE J
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5624
Practice Address - Country:US
Practice Address - Phone:770-489-1450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1750531414OtherINDIVIDUAL NPI