Provider Demographics
NPI:1104176163
Name:GREEN, MATTHEW PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PAUL
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 1:1405 78TH ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386-9723
Mailing Address - Country:US
Mailing Address - Phone:952-443-2994
Mailing Address - Fax:952-443-2918
Practice Address - Street 1:1405 78TH ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:MN
Practice Address - Zip Code:55386-9723
Practice Address - Country:US
Practice Address - Phone:952-443-2994
Practice Address - Fax:952-443-2918
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13156122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist