Provider Demographics
NPI:1407460942
Name:GREENE, JACOB ALAN (DMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ALAN
Last Name:GREENE
Suffix:
Gender:M
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:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:WV
Mailing Address - Zip Code:26801-0097
Mailing Address - Country:US
Mailing Address - Phone:304-897-5915
Mailing Address - Fax:304-897-8472
Practice Address - Street 1:111 S GROVE ST STE 1
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1805
Practice Address - Country:US
Practice Address - Phone:304-257-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0161061223G0001X
WV46711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice