Provider Demographics
NPI:1922165216
Name:PALMER, MATHEW GREG (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:GREG
Last Name:PALMER
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 1:1111 SUFFOLK DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-1608
Mailing Address - Country:US
Mailing Address - Phone:701-340-3466
Mailing Address - Fax:
Practice Address - Street 1:1111 SUFFOLK DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-1608
Practice Address - Country:US
Practice Address - Phone:608-752-6848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019381122300000X
WI6658-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXVAD 000Medicare UPIN