Provider Demographics
NPI:1770657124
Name:EDWARD J GREEN DMD PC
Entity Type:Organization
Organization Name:EDWARD J GREEN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:S CORP PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR OF DENTAL MED
Authorized Official - Phone:229-883-3071
Mailing Address - Street 1:PO BOX 70907
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-0907
Mailing Address - Country:US
Mailing Address - Phone:229-883-3071
Mailing Address - Fax:229-883-5184
Practice Address - Street 1:1505 W THIRD AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3647
Practice Address - Country:US
Practice Address - Phone:229-883-3071
Practice Address - Fax:229-883-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN098071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00267044BMedicaid