Provider Demographics
NPI:1497325583
Name:GREENE, RANDOLPH III (DDS)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:GREENE
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 S COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-4948
Mailing Address - Country:US
Mailing Address - Phone:540-300-6376
Mailing Address - Fax:
Practice Address - Street 1:303 S COLORADO ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-4948
Practice Address - Country:US
Practice Address - Phone:540-300-6376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014175101223G0001X
VA-0401417510122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist