Provider Demographics
NPI:1588783344
Name:GREEN, AMANDA S (DMD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:S
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 1:763 E. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302
Mailing Address - Country:US
Mailing Address - Phone:864-585-8558
Mailing Address - Fax:864-580-4242
Practice Address - Street 1:763 E. MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302
Practice Address - Country:US
Practice Address - Phone:864-585-8558
Practice Address - Fax:864-580-4242
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 37031223G0001X
SC738PD1223P0221X
SC37031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9313Medicaid
SCZA9481Medicaid
SCZX3703Medicaid