Provider Demographics
NPI:1558513218
Name:GREEN, JOHN EDDIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDDIE
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 1:38 PEMBROKE LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-2594
Mailing Address - Country:US
Mailing Address - Phone:210-641-2943
Mailing Address - Fax:
Practice Address - Street 1:38 PEMBROKE LN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-2594
Practice Address - Country:US
Practice Address - Phone:210-641-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX235071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice