Provider Demographics
NPI:1215018239
Name:DRBOHLAV, MATTHEW (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DRBOHLAV
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:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:HOTCHKISS
Mailing Address - State:CO
Mailing Address - Zip Code:81419-0186
Mailing Address - Country:US
Mailing Address - Phone:970-872-2299
Mailing Address - Fax:970-872-4704
Practice Address - Street 1:158 EAST BRIDGE STREET
Practice Address - Street 2:
Practice Address - City:HOTCHKISS
Practice Address - State:CO
Practice Address - Zip Code:81419
Practice Address - Country:US
Practice Address - Phone:970-872-2299
Practice Address - Fax:970-872-4704
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO74031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice