Provider Demographics
NPI:1003308099
Name:WOOD, MATTHEW TYLER
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TYLER
Last Name:WOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2753 JANITELL RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4102
Mailing Address - Country:US
Mailing Address - Phone:719-355-5305
Mailing Address - Fax:
Practice Address - Street 1:7610 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-9344
Practice Address - Country:US
Practice Address - Phone:719-539-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN002035851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE$$$$$$$$$Other$$$$$$$$$