Provider Demographics
NPI:1841641701
Name:GREEN, KALA MICHELE (DMD)
Entity type:Individual
Prefix:DR
First Name:KALA
Middle Name:MICHELE
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 1:3455 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4101
Mailing Address - Country:US
Mailing Address - Phone:770-921-1115
Mailing Address - Fax:
Practice Address - Street 1:3455 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-4101
Practice Address - Country:US
Practice Address - Phone:770-921-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0152011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice