Provider Demographics
NPI:1598787301
Name:GREEN, TIM DAVIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIM
Middle Name:DAVIS
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 1:8135 SOULE RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1578
Mailing Address - Country:US
Mailing Address - Phone:315-622-2523
Mailing Address - Fax:315-622-0594
Practice Address - Street 1:8135 SOULE RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-1578
Practice Address - Country:US
Practice Address - Phone:315-622-2523
Practice Address - Fax:315-622-0594
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0344211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice