Provider Demographics
NPI:1770608119
Name:GREEN, JACK L JR (DDS MSD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:L
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1201 48TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5432
Mailing Address - Country:US
Mailing Address - Phone:843-449-1444
Mailing Address - Fax:843-449-2768
Practice Address - Street 1:1201 48TH AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5432
Practice Address - Country:US
Practice Address - Phone:843-449-1444
Practice Address - Fax:843-449-2768
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16291223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics