Provider Demographics
NPI:1376948836
Name:KEITH A WING DDS & MATTHEW P MACK CHRISTOPHER R SMITH DDS INC
Entity Type:Organization
Organization Name:KEITH A WING DDS & MATTHEW P MACK CHRISTOPHER R SMITH DDS INC
Other - Org Name:WING, MACK & SMITH DDS, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-344-9155
Mailing Address - Street 1:1420 DICKERSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1844
Mailing Address - Country:US
Mailing Address - Phone:740-344-9155
Mailing Address - Fax:740-344-5668
Practice Address - Street 1:1420 DICKERSON ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1844
Practice Address - Country:US
Practice Address - Phone:740-344-9155
Practice Address - Fax:740-344-5668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30 0214741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty