Provider Demographics
NPI:1932181674
Name:GREEN, MICHAEL LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAWRENCE
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 1:541 N 580 W
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3164
Mailing Address - Country:US
Mailing Address - Phone:916-241-5515
Mailing Address - Fax:
Practice Address - Street 1:286 E 12200 S
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7817
Practice Address - Country:US
Practice Address - Phone:801-877-3664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9257847-9921122300000X
CA34706122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist