Provider Demographics
NPI:1770892705
Name:GREEN, JOHN MARSHALL III (DDS FACS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARSHALL
Last Name:GREEN
Suffix:III
Gender:M
Credentials:DDS FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 THIMBLE SHOALS BLVD STE B-3
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4533
Mailing Address - Country:US
Mailing Address - Phone:757-223-5800
Mailing Address - Fax:
Practice Address - Street 1:895 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2105
Practice Address - Country:US
Practice Address - Phone:540-344-7252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6055122300000X
VA04380003571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist