Provider Demographics
NPI:1437453420
Name:MATZELLE, ERIC (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:MATZELLE
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 1:15972 NW RONDOS DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-9238
Mailing Address - Country:US
Mailing Address - Phone:503-702-4088
Mailing Address - Fax:
Practice Address - Street 1:18807 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-6735
Practice Address - Country:US
Practice Address - Phone:503-657-0399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9528122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist