Provider Demographics
NPI:1972584969
Name:GREEN, ANTHONY TREVOR (D D S)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:TREVOR
Last Name:GREEN
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17836 WEXFORD TER
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3024
Mailing Address - Country:US
Mailing Address - Phone:718-739-1300
Mailing Address - Fax:718-739-0966
Practice Address - Street 1:17836 WEXFORD TER
Practice Address - Street 2:SUITE 2E
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3024
Practice Address - Country:US
Practice Address - Phone:718-739-1300
Practice Address - Fax:718-739-0966
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04732991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02166558Medicaid
NY02166558Medicaid
NY486701Medicare UPIN