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 1:12 RIVER TERRACE CT
Mailing Address - Street 2:APARTMENT 204
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3713
Mailing Address - Country:US
Mailing Address - Phone:701-520-3255
Mailing Address - Fax:
Practice Address - Street 1:12 RIVER TERRACE CT
Practice Address - Street 2:APARTMENT 204
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3713
Practice Address - Country:US
Practice Address - Phone:701-520-3255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13156122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist