Provider Demographics
NPI:1477644987
Name:MATTINGLY, STEPHEN P (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:P
Last Name:MATTINGLY
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 1:805 EASTERN BY-PASS
Mailing Address - Street 2:SUITE #4
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475
Mailing Address - Country:US
Mailing Address - Phone:859-623-0222
Mailing Address - Fax:859-624-3440
Practice Address - Street 1:805 EASTERN BY-PASS
Practice Address - Street 2:SUITE #4
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475
Practice Address - Country:US
Practice Address - Phone:859-623-0222
Practice Address - Fax:859-624-3440
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6125122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60061256Medicaid