Provider Demographics
NPI:1053510966
Name:WOOLSEY, MATTHEW W (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:W
Last Name:WOOLSEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 W ELLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1407
Mailing Address - Country:US
Mailing Address - Phone:503-623-8010
Mailing Address - Fax:503-623-9344
Practice Address - Street 1:155 W ELLENDALE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1407
Practice Address - Country:US
Practice Address - Phone:503-623-8010
Practice Address - Fax:503-623-9344
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9265122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist