Provider Demographics
NPI:1710069612
Name:GREEN-DILEO, EVIE ALICE (DDS)
Entity Type:Individual
Prefix:DR
First Name:EVIE
Middle Name:ALICE
Last Name:GREEN-DILEO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:EVIE
Other - Middle Name:ALICE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1208 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-5535
Mailing Address - Country:US
Mailing Address - Phone:409-883-3131
Mailing Address - Fax:409-883-6811
Practice Address - Street 1:1208 W ELM ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-5535
Practice Address - Country:US
Practice Address - Phone:409-883-3131
Practice Address - Fax:409-883-6811
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX169061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2001054OtherBCBS
TX706854OtherUNITED CONCORDIA