Provider Demographics
NPI:1518008093
Name:GREEN, KEVAN S (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVAN
Middle Name:S
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 1:215 E BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON HEIGHTS
Mailing Address - State:PA
Mailing Address - Zip Code:19018-1605
Mailing Address - Country:US
Mailing Address - Phone:610-623-4493
Mailing Address - Fax:610-623-0871
Practice Address - Street 1:215 E BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON HEIGHTS
Practice Address - State:PA
Practice Address - Zip Code:19018-1605
Practice Address - Country:US
Practice Address - Phone:610-623-4493
Practice Address - Fax:610-623-0871
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI014670001223P0300X
PADS024064L1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics