Provider Demographics
NPI:1104371483
Name:CARMODY, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CARMODY
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:PO BOX 1340
Mailing Address - Street 2:
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-1340
Mailing Address - Country:US
Mailing Address - Phone:509-422-5700
Mailing Address - Fax:509-422-7680
Practice Address - Street 1:1015 COLUMBIA
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WA
Practice Address - Zip Code:98813
Practice Address - Country:US
Practice Address - Phone:509-422-5700
Practice Address - Fax:509-422-7680
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60674038122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist