Provider Demographics
NPI:1558314385
Name:GREEN, JOEL D (DDS)
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:D
Last Name:GREEN
Suffix:
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 1:251 N BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36603-5827
Mailing Address - Country:US
Mailing Address - Phone:251-690-8158
Mailing Address - Fax:251-544-2188
Practice Address - Street 1:950 W COY SMITH HWY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:AL
Practice Address - Zip Code:36560-3201
Practice Address - Country:US
Practice Address - Phone:251-829-9884
Practice Address - Fax:251-829-9507
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALETD0008122300000X
AL5458C1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1063439065OtherNPI GROUP PAYEE NUMBER
AL631400174Medicaid
AL630000013Medicaid
AL011846OtherMEDICARE GROUP PAYEE NUMBER
AL631400174Medicaid
AL1063439065OtherNPI GROUP PAYEE NUMBER