Provider Demographics
NPI:1649380981
Name:GREEN, ALICE SUE (DDS)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:SUE
Last Name:GREEN
Suffix:
Gender:F
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:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46065-0040
Mailing Address - Country:US
Mailing Address - Phone:765-379-3539
Mailing Address - Fax:765-379-3433
Practice Address - Street 1:54 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46065-9459
Practice Address - Country:US
Practice Address - Phone:765-379-3539
Practice Address - Fax:765-379-3433
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120067081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice