Provider Demographics
NPI:1619087954
Name:GREEN, RALPH M (DMD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:M
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 1:3809-B POPLAR LEVEL RD.
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213
Mailing Address - Country:US
Mailing Address - Phone:502-459-4273
Mailing Address - Fax:502-459-4343
Practice Address - Street 1:3809-B POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1429
Practice Address - Country:US
Practice Address - Phone:502-459-4273
Practice Address - Fax:502-459-4343
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51961223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYT-54089Medicare UPIN
KY64051964Medicare ID - Type Unspecified