Provider Demographics
NPI:1467914606
Name:CARMODY, MATTHEW (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CARMODY
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 1:1452 E REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3710
Mailing Address - Country:US
Mailing Address - Phone:402-681-4101
Mailing Address - Fax:
Practice Address - Street 1:4888 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-6007
Practice Address - Country:US
Practice Address - Phone:801-997-1137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12558925-99241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice