Provider Demographics
NPI:1164555629
Name:MOLITOR, MATTHEW LEO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LEO
Last Name:MOLITOR
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 1:1759 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1004
Mailing Address - Country:US
Mailing Address - Phone:530-758-6420
Mailing Address - Fax:530-758-3856
Practice Address - Street 1:1759 OAK AVE
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-1004
Practice Address - Country:US
Practice Address - Phone:530-758-6420
Practice Address - Fax:530-758-3856
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA416531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics