Provider Demographics
NPI:1538459409
Name:GREEN, DORY (DMD, FAGD)
Entity Type:Individual
Prefix:DR
First Name:DORY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:DMD, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 S ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1837
Mailing Address - Country:US
Mailing Address - Phone:954-522-8554
Mailing Address - Fax:
Practice Address - Street 1:4100 DAVIE RD STE 104
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-3655
Practice Address - Country:US
Practice Address - Phone:954-682-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0383871223G0001X
NJ22DI024651001223G0001X
FLDN195771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008275900Medicaid