Provider Demographics
NPI:1497065551
Name:GREEN, JOHN ARMSTRONG (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ARMSTRONG
Last Name:GREEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5029 S 1200 E
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4297
Mailing Address - Country:US
Mailing Address - Phone:801-648-3653
Mailing Address - Fax:
Practice Address - Street 1:5029 S 1200 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4297
Practice Address - Country:US
Practice Address - Phone:801-648-3653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60434325122300000X
UT7692415-9922122300000X
ORD100291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice