Provider Demographics
NPI:1528398484
Name:DR JACQUELYN GREEN DDS LOVERS LANE PLLC
Entity Type:Organization
Organization Name:DR JACQUELYN GREEN DDS LOVERS LANE PLLC
Other - Org Name:FLOSS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-352-0101
Mailing Address - Street 1:5730 W LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-5116
Mailing Address - Country:US
Mailing Address - Phone:214-352-0101
Mailing Address - Fax:
Practice Address - Street 1:5730 W LOVERS LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-5116
Practice Address - Country:US
Practice Address - Phone:214-352-0101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-28
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty