Provider Demographics
NPI:1003960436
Name:DURHAM, MATTHEW P (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:P
Last Name:DURHAM
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 1:2700 5 MILE NERD 201
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6516
Mailing Address - Country:US
Mailing Address - Phone:616-361-1727
Mailing Address - Fax:616-361-0060
Practice Address - Street 1:2700 5 MILE RD NE
Practice Address - Street 2:STE. #201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1710
Practice Address - Country:US
Practice Address - Phone:616-361-1727
Practice Address - Fax:616-361-1455
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901076681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4361190Medicaid