Provider Demographics
NPI:1417484197
Name:LATTA, MATTHEW (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LATTA
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:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43044-0103
Mailing Address - Country:US
Mailing Address - Phone:937-824-2252
Mailing Address - Fax:937-834-2269
Practice Address - Street 1:18 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:OH
Practice Address - Zip Code:43044-1111
Practice Address - Country:US
Practice Address - Phone:937-834-2252
Practice Address - Fax:937-834-2269
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0250471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice