Provider Demographics
NPI:1043470479
Name:GEBHARDT, MATT (DDS, MS, PC)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:
Last Name:GEBHARDT
Suffix:
Gender:M
Credentials:DDS, MS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 CORTEZ CT
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2507
Mailing Address - Country:US
Mailing Address - Phone:541-776-7640
Mailing Address - Fax:541-776-7630
Practice Address - Street 1:831 ALDER CREEK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8900
Practice Address - Country:US
Practice Address - Phone:541-776-7640
Practice Address - Fax:541-776-7640
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD90601223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics