Provider Demographics
NPI:1073643854
Name:MATTHEW R. LARK, D.D.S., P.C., INC.
Entity Type:Organization
Organization Name:MATTHEW R. LARK, D.D.S., P.C., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:BRIGID
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7900
Mailing Address - Street 1:4315 N HOLLAND SYLVANIA RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-2507
Mailing Address - Country:US
Mailing Address - Phone:419-824-7900
Mailing Address - Fax:419-824-7877
Practice Address - Street 1:4315 N HOLLAND SYLVANIA RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-2507
Practice Address - Country:US
Practice Address - Phone:419-824-7900
Practice Address - Fax:419-824-7877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0171591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty