Provider Demographics
NPI:1629196696
Name:GREEN, DANIELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 POQUONNOCK RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340
Mailing Address - Country:US
Mailing Address - Phone:860-445-9765
Mailing Address - Fax:860-445-2757
Practice Address - Street 1:1100 POQUONNOCK RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-445-9765
Practice Address - Fax:860-445-2757
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0077201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice