Provider Demographics
NPI:1467788497
Name:GREEN, KIMBERLY MICHELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:MICHELLE
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 1:230 E 10TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-5784
Mailing Address - Country:US
Mailing Address - Phone:256-741-7340
Mailing Address - Fax:256-741-7373
Practice Address - Street 1:2700 5TH AVE N
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35020-4170
Practice Address - Country:US
Practice Address - Phone:205-425-1327
Practice Address - Fax:205-425-2864
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5722122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL002515745OtherUNITED CONCORDIA
AL120062Medicaid