Provider Demographics
NPI:1750874210
Name:GREEN, JUSTIN A (DMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8118 SYCAMORE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-3937
Mailing Address - Country:US
Mailing Address - Phone:740-525-1125
Mailing Address - Fax:
Practice Address - Street 1:2241 STATE ST STE C
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4949
Practice Address - Country:US
Practice Address - Phone:812-945-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-10
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10759122300000X
IN12013955A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist