Provider Demographics
NPI:1407489826
Name:DANA MATLOCK, DDS, LLC
Entity Type:Organization
Organization Name:DANA MATLOCK, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-264-2800
Mailing Address - Street 1:123 SE DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-4426
Mailing Address - Country:US
Mailing Address - Phone:541-264-2800
Mailing Address - Fax:541-265-8617
Practice Address - Street 1:123 SE DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4426
Practice Address - Country:US
Practice Address - Phone:541-264-2800
Practice Address - Fax:541-265-8617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental