Provider Demographics
NPI:1609995786
Name:GREENE, STACEY ANDREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ANDREW
Last Name:GREENE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:709 E MARKET ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-3265
Mailing Address - Country:US
Mailing Address - Phone:336-691-8084
Mailing Address - Fax:336-691-9285
Practice Address - Street 1:709 E MARKET ST
Practice Address - Street 2:SUITE 204
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-3265
Practice Address - Country:US
Practice Address - Phone:336-691-8084
Practice Address - Fax:336-691-9285
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC61391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC141840759OtherTAX ID
NC216285OtherCIGNA
NC8993378Medicaid
NC93378OtherBLUE CROSS
NC970026OtherUNITED CONCORDIA
NC141840759OtherTAX ID