Provider Demographics
NPI:1265695159
Name:GREEN, JORDON J (DDS)
Entity type:Individual
Prefix:DR
First Name:JORDON
Middle Name:J
Last Name:GREEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 N GARFIELD ST STE B12
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-2653
Mailing Address - Country:US
Mailing Address - Phone:432-682-8941
Mailing Address - Fax:
Practice Address - Street 1:4610 N GARFIELD ST STE B12
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-2653
Practice Address - Country:US
Practice Address - Phone:432-682-8941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ75761223G0001X
TX260981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice