Provider Demographics
NPI:1780902965
Name:GREEN, RALPH E JR (DDS)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:E
Last Name:GREEN
Suffix:JR
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 1:1904 W PARKSIDE LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-1228
Mailing Address - Country:US
Mailing Address - Phone:877-227-9892
Mailing Address - Fax:623-321-6268
Practice Address - Street 1:428 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-3768
Practice Address - Country:US
Practice Address - Phone:877-227-9892
Practice Address - Fax:623-321-6268
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN11301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist