Provider Demographics
NPI:1003034976
Name:MATTINSON, KEITH S (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:S
Last Name:MATTINSON
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 1:1172 E 100 N
Mailing Address - Street 2:SUITE # 3
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-1667
Mailing Address - Country:US
Mailing Address - Phone:801-465-5000
Mailing Address - Fax:
Practice Address - Street 1:1172 E 100 N
Practice Address - Street 2:SUITE # 3
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1667
Practice Address - Country:US
Practice Address - Phone:801-465-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14498999221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice