Provider Demographics
NPI:1720260425
Name:GREEN, ROBERT EVANS (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EVANS
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:PO BOX 3286
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-3286
Mailing Address - Country:US
Mailing Address - Phone:909-214-9194
Mailing Address - Fax:
Practice Address - Street 1:7018 BLAIR RD
Practice Address - Street 2:
Practice Address - City:CALIPATRIA
Practice Address - State:CA
Practice Address - Zip Code:92233-9633
Practice Address - Country:US
Practice Address - Phone:760-348-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist