Provider Demographics
NPI:1295916450
Name:GREEN, RYAN Q (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:Q
Last Name:GREEN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 PINE ST
Mailing Address - Street 2:SUITE 1-D
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-2449
Mailing Address - Country:US
Mailing Address - Phone:325-232-8939
Mailing Address - Fax:325-232-8943
Practice Address - Street 1:1904 PINE ST
Practice Address - Street 2:SUITE 1-D
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2449
Practice Address - Country:US
Practice Address - Phone:325-232-8939
Practice Address - Fax:325-232-8943
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242371223S0112X
TXN4439174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2119414-01Medicaid