Provider Demographics
NPI:1386027704
Name:ENNS, MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:ENNS
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 1:30406 HAUN RD
Mailing Address - Street 2:STE 740
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-6816
Mailing Address - Country:US
Mailing Address - Phone:951-679-4624
Mailing Address - Fax:951-679-2221
Practice Address - Street 1:30406 HAUN RD
Practice Address - Street 2:STE 740
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-6816
Practice Address - Country:US
Practice Address - Phone:951-679-4624
Practice Address - Fax:951-679-2221
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856836122300000X
CA101260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist