Provider Demographics
NPI:1477693802
Name:MATTHEWS, BLAKE LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:LYNN
Last Name:MATTHEWS
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 1:3540 NORTH 465 WEST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3610 N UNIVERSITY AVE
Practice Address - Street 2:#200
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4437
Practice Address - Country:US
Practice Address - Phone:801-377-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2227549899221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice