Provider Demographics
NPI:1740760974
Name:GREEN, DUSTIN PAUL
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:PAUL
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 N TRAVIS ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-5139
Mailing Address - Country:US
Mailing Address - Phone:972-983-2336
Mailing Address - Fax:
Practice Address - Street 1:1306 N TRAVIS ST
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-5139
Practice Address - Country:US
Practice Address - Phone:972-983-2336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT58792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer