Healthcare Provider Details

I. General information

NPI: 1710688973
Provider Name (Legal Business Name): MATTHEW LYNN OXFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 05/27/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST STE 2F
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4622
  • Fax:
Mailing address:
  • Phone: 469-995-9819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901602218
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901602218
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: