Provider Demographics
NPI:1306859483
Name:MATLACH, CHARLES ALAN
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALAN
Last Name:MATLACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5281 VIA DEL SOLE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-636-8215
Mailing Address - Fax:716-688-2984
Practice Address - Street 1:8397 BOSTON STATE RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:NY
Practice Address - Zip Code:14025-9651
Practice Address - Country:US
Practice Address - Phone:716-941-5433
Practice Address - Fax:716-941-5972
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY 32221122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist