Provider Demographics
NPI:1417188178
Name:MOEN, MATTHEW CASPER (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:CASPER
Last Name:MOEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 WUNDERLIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-2200
Mailing Address - Country:US
Mailing Address - Phone:406-538-2376
Mailing Address - Fax:406-538-3557
Practice Address - Street 1:215 WUNDERLIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-2200
Practice Address - Country:US
Practice Address - Phone:406-538-2376
Practice Address - Fax:406-538-3557
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT23681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice