Provider Demographics
NPI:1386840809
Name:DR GREEN & ASSOCIATES PC
Entity type:Organization
Organization Name:DR GREEN & ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILEY
Authorized Official - Middle Name:F
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-659-3078
Mailing Address - Street 1:PO BOX 301
Mailing Address - Street 2:1961 S JACKSON ST
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-3359
Mailing Address - Country:US
Mailing Address - Phone:765-659-3078
Mailing Address - Fax:
Practice Address - Street 1:1961 SOUTH JACKSON ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-3359
Practice Address - Country:US
Practice Address - Phone:765-659-3078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54000603A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty