Provider Demographics
NPI:1942436589
Name:GREEN, CHAZ DAJUAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAZ
Middle Name:DAJUAN
Last Name:GREEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19815 MARVIN RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-4215
Mailing Address - Country:US
Mailing Address - Phone:216-374-8354
Mailing Address - Fax:
Practice Address - Street 1:19815 MARVIN RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-4215
Practice Address - Country:US
Practice Address - Phone:216-374-8354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH28261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice