Provider Demographics
NPI:1326576182
Name:VOGT, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VOGT
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 1:11 S MILL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-3680
Mailing Address - Country:US
Mailing Address - Phone:724-698-2132
Mailing Address - Fax:844-399-0385
Practice Address - Street 1:1375 S LEBANON ST STE 200
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-2951
Practice Address - Country:US
Practice Address - Phone:765-484-8951
Practice Address - Fax:844-399-0385
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012701A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist