Provider Demographics
NPI:1558428086
Name:GREEN, JOSHUA (DDS)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
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 1:122 SOUTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-3375
Mailing Address - Country:US
Mailing Address - Phone:406-549-5861
Mailing Address - Fax:
Practice Address - Street 1:913 SW HIGGINS AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1461
Practice Address - Country:US
Practice Address - Phone:406-549-5861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT21741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice