Provider Demographics
NPI:1043308331
Name:GREEN, ROBERT TYLER (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TYLER
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 1:1805 W WHITE OAK TERRACE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3950
Mailing Address - Country:US
Mailing Address - Phone:936-588-4433
Mailing Address - Fax:936-588-4603
Practice Address - Street 1:1805 W WHITE OAK TERRACE
Practice Address - Street 2:SUITE A
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3950
Practice Address - Country:US
Practice Address - Phone:936-588-4433
Practice Address - Fax:936-588-4603
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18952122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist