Provider Demographics
NPI:1255792750
Name:MATZKOWITZ, IAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:MATZKOWITZ
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 1:1551 LARIMER ST APT 2203
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-1636
Mailing Address - Country:US
Mailing Address - Phone:727-692-3478
Mailing Address - Fax:
Practice Address - Street 1:1551 LARIMER ST APT 2203
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-1636
Practice Address - Country:US
Practice Address - Phone:727-692-3478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002032721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000158519Medicaid