Provider Demographics
NPI:1861606584
Name:GREEN, MICHAEL BRANDON (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRANDON
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 1:9217 REDWOOD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5826
Mailing Address - Country:US
Mailing Address - Phone:801-566-1873
Mailing Address - Fax:801-307-0215
Practice Address - Street 1:9217 REDWOOD RD
Practice Address - Street 2:SUITE B
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5826
Practice Address - Country:US
Practice Address - Phone:801-566-1873
Practice Address - Fax:801-307-0215
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT62299251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528373269007Medicaid