Basic Information
Provider Information | |||||||||
NPI: | 1558314385 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREEN | ||||||||
FirstName: | JOEL | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 251 N BAYOU ST | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366035827 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516908158 | ||||||||
FaxNumber: | 2515442188 | ||||||||
Practice Location | |||||||||
Address1: | 950 W COY SMITH HWY | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | AL | ||||||||
PostalCode: | 365603201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2518299884 | ||||||||
FaxNumber: | 2518299507 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 02/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | ETD0008 | AL | N |   | Dental Providers | Dentist |   | 1223G0001X | 5458C | AL | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 1063439065 | 01 | AL | NPI GROUP PAYEE NUMBER | OTHER | 631400174 | 05 | AL |   | MEDICAID | 630000013 | 05 | AL |   | MEDICAID | 011846 | 01 | AL | MEDICARE GROUP PAYEE NUMBER | OTHER |