Provider Demographics
NPI:1467540906
Name:GREEN, RHONDA NICOLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:RHONDA
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 GODFREY RD
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1808
Mailing Address - Country:US
Mailing Address - Phone:618-466-5508
Mailing Address - Fax:618-466-3515
Practice Address - Street 1:3003 GODFREY RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1808
Practice Address - Country:US
Practice Address - Phone:618-466-5508
Practice Address - Fax:618-466-3515
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024529122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist