Provider Demographics
NPI:1245577329
Name:CHAD D MATONE DDS PA
Entity Type:Organization
Organization Name:CHAD D MATONE DDS PA
Other - Org Name:MALVERN DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:D
Authorized Official - Last Name:MATONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-490-1293
Mailing Address - Street 1:230 PINE BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-4228
Mailing Address - Country:US
Mailing Address - Phone:501-337-4908
Mailing Address - Fax:501-337-9929
Practice Address - Street 1:230 PINE BLUFF ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4228
Practice Address - Country:US
Practice Address - Phone:501-337-4908
Practice Address - Fax:501-337-9929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR35741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR164408608Medicaid
AR5Y893OtherARKANSAS BLUE CROSS BLUE SHEILD