Provider Demographics
NPI:1821262601
Name:GREEN ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:GREEN ORTHODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-542-9940
Mailing Address - Street 1:329 WARFIELD BLVD
Mailing Address - Street 2:STE G
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8903
Mailing Address - Country:US
Mailing Address - Phone:931-542-9940
Mailing Address - Fax:
Practice Address - Street 1:329 WARFIELD BLVD
Practice Address - Street 2:STE G
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8903
Practice Address - Country:US
Practice Address - Phone:931-542-9940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN81511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty