Provider Demographics
NPI:1770515389
Name:GREEN, TIFFANY PRISCILLA (DMD)
Entity type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:PRISCILLA
Last Name:GREEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LUCKNEY STATION RD
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8402
Mailing Address - Country:US
Mailing Address - Phone:601-992-8000
Mailing Address - Fax:601-992-8262
Practice Address - Street 1:101 LUCKNEY STATION RD
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8402
Practice Address - Country:US
Practice Address - Phone:601-992-8000
Practice Address - Fax:601-992-8262
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPEDO-399-061223P0221X
MS3296-041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSFG0254766OtherDEA