Provider Demographics
NPI:1336122118
Name:CLEGG, MATTHEW S (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:S
Last Name:CLEGG
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2022
Mailing Address - Country:US
Mailing Address - Phone:509-758-4181
Mailing Address - Fax:509-758-4756
Practice Address - Street 1:802 7TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2022
Practice Address - Country:US
Practice Address - Phone:509-758-4181
Practice Address - Fax:509-758-4756
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000101801223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602 510 100OtherUNIFIED BUSINESS IDENT.