Provider Demographics
NPI:1023622347
Name:GREEN, JON TYLER (DMD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:TYLER
Last Name:GREEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA DENTAL HEALTH ACTIVITY
Mailing Address - Street 2:652 HAMILTON RD.
Mailing Address - City:FT. SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503
Mailing Address - Country:US
Mailing Address - Phone:580-442-3905
Mailing Address - Fax:
Practice Address - Street 1:USA DENTAL HEALTH ACTIVITY
Practice Address - Street 2:652 HAMILTON RD.
Practice Address - City:FT. SILL
Practice Address - State:OK
Practice Address - Zip Code:73503
Practice Address - Country:US
Practice Address - Phone:580-442-3905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5147122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist