Provider Demographics
NPI:1699113365
Name:GREEN, ERIN RUSSELL (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIN
Middle Name:RUSSELL
Last Name:GREEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 LAKE VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6743
Mailing Address - Country:US
Mailing Address - Phone:601-850-2145
Mailing Address - Fax:
Practice Address - Street 1:1075 LAKE VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6743
Practice Address - Country:US
Practice Address - Phone:601-992-1605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3688-131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice