Provider Demographics
NPI:1538398003
Name:GREEN, RANDI CLINE (DMD)
Entity type:Individual
Prefix:DR
First Name:RANDI
Middle Name:CLINE
Last Name:GREEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:RANDI
Other - Middle Name:
Other - Last Name:CLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:7036 COPPER CV
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1043
Mailing Address - Country:US
Mailing Address - Phone:601-573-8484
Mailing Address - Fax:601-573-8484
Practice Address - Street 1:102 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6039
Practice Address - Country:US
Practice Address - Phone:601-573-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS3505-09122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program