Provider Demographics
NPI:1619238987
Name:GREEN, MATTHEW JONATHON (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JONATHON
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 1:6266 VINEYARD AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-5919
Mailing Address - Country:US
Mailing Address - Phone:248-760-4959
Mailing Address - Fax:
Practice Address - Street 1:519 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-9559
Practice Address - Country:US
Practice Address - Phone:734-439-1543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010206631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice