Provider Demographics
NPI:1346370178
Name:LARK, MATTHEW R (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:LARK
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 1:4315 N HOLLAND SYLVANIA RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-2507
Mailing Address - Country:US
Mailing Address - Phone:419-824-7900
Mailing Address - Fax:419-824-7877
Practice Address - Street 1:4315 N HOLLAND SYLVANIA RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-2507
Practice Address - Country:US
Practice Address - Phone:419-824-7900
Practice Address - Fax:419-824-7877
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0171591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0509015Medicaid