Provider Demographics
NPI:1124687082
Name:GREEN, JONNITA (DDS)
Entity type:Individual
Prefix:DR
First Name:JONNITA
Middle Name:
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 1:1403 PEACH BLOSSOM CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1623
Mailing Address - Country:US
Mailing Address - Phone:513-256-1258
Mailing Address - Fax:
Practice Address - Street 1:333 CONOVER DR STE D
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-1900
Practice Address - Country:US
Practice Address - Phone:513-318-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist