Provider Demographics
NPI:1700060936
Name:GREENE, JEFFREY ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:GREENE
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 1:715 S MAIN ST
Mailing Address - Street 2:2
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-5717
Mailing Address - Country:US
Mailing Address - Phone:714-647-0797
Mailing Address - Fax:
Practice Address - Street 1:715 S MAIN ST
Practice Address - Street 2:2
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5717
Practice Address - Country:US
Practice Address - Phone:714-647-0797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197391223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB19739-01Medicare PIN