Provider Demographics
NPI:1558555367
Name:GREEN, ERIC R (DMD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:R
Last Name:GREEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8709 HUNTERS GREEN DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2309
Mailing Address - Country:US
Mailing Address - Phone:813-221-2273
Mailing Address - Fax:813-929-7273
Practice Address - Street 1:8709 HUNTERS GREEN DR
Practice Address - Street 2:SUITE 102
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2309
Practice Address - Country:US
Practice Address - Phone:813-221-2273
Practice Address - Fax:813-929-7273
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN158291223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics