Provider Demographics
NPI:1164541348
Name:DEATLEY, IRVIN MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:IRVIN
Middle Name:MATTHEW
Last Name:DEATLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 DYER ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3524
Mailing Address - Country:US
Mailing Address - Phone:870-425-9893
Mailing Address - Fax:
Practice Address - Street 1:320 E 7TH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-4416
Practice Address - Country:US
Practice Address - Phone:870-425-1441
Practice Address - Fax:870-425-1445
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3573122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist