Provider Demographics
NPI:1558704122
Name:GREEN, BEVERLY (DDS)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 LYONS RD APT 204
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33063-9269
Mailing Address - Country:US
Mailing Address - Phone:954-854-9753
Mailing Address - Fax:
Practice Address - Street 1:9440 W COMMERCIAL BLVD STE 105
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33351-4329
Practice Address - Country:US
Practice Address - Phone:954-900-3180
Practice Address - Fax:954-440-4388
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist