Provider Demographics
NPI:1811512932
Name:GREEN, KEVAN S (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVAN
Middle Name:S
Last Name:GREEN
Suffix:
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 1:133 W HULL DR
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-3703
Mailing Address - Country:US
Mailing Address - Phone:740-363-3871
Mailing Address - Fax:740-369-6616
Practice Address - Street 1:133 W HULL DR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-3703
Practice Address - Country:US
Practice Address - Phone:740-363-3871
Practice Address - Fax:740-369-6616
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0261911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice