Provider Demographics
NPI:1891849451
Name:GREEN, ROSE MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:MARIE
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 1:1625 PLEASANT HILL RD STE 140
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5863
Mailing Address - Country:US
Mailing Address - Phone:678-924-4888
Mailing Address - Fax:678-924-4898
Practice Address - Street 1:1625 PLEASANT HILL RD STE 140
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5863
Practice Address - Country:US
Practice Address - Phone:678-924-4888
Practice Address - Fax:678-924-4898
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012094122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0090132622Medicaid