Provider Demographics
NPI:1467783506
Name:GREEN, DENNIS JASON (IDC)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:JASON
Last Name:GREEN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 CROSS BILL TRL
Mailing Address - Street 2:
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29410-8231
Mailing Address - Country:US
Mailing Address - Phone:808-989-0237
Mailing Address - Fax:
Practice Address - Street 1:1050 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-3544
Practice Address - Country:US
Practice Address - Phone:843-743-7000
Practice Address - Fax:843-574-8212
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$OtherSERVICE NUMBER