Provider Demographics
NPI:1972997716
Name:GREEN, MATTHEW P (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:P
Last Name:GREEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MAPLE AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4259
Mailing Address - Country:US
Mailing Address - Phone:516-766-6755
Mailing Address - Fax:
Practice Address - Street 1:24 MAPLE AVE STE 6
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4259
Practice Address - Country:US
Practice Address - Phone:516-766-6755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0616341223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN25480OtherDENTAL LICENSE