Provider Demographics
NPI:1609268788
Name:GREEN, DALLAS (DMS, PA-C)
Entity Type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:DMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6255 W SUNSET BLVD FL 21
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7422
Mailing Address - Country:US
Mailing Address - Phone:323-860-5200
Mailing Address - Fax:323-467-7119
Practice Address - Street 1:3661 S MIAMI AVE
Practice Address - Street 2:SUITE 806
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4236
Practice Address - Country:US
Practice Address - Phone:786-497-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9108459363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant