Provider Demographics
NPI:1538505615
Name:DAMIN, MATTHEW NICHOLSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:NICHOLSON
Last Name:DAMIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 DESTINY LN
Mailing Address - Street 2:SUITE 119
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-1087
Mailing Address - Country:US
Mailing Address - Phone:270-393-9925
Mailing Address - Fax:270-393-9928
Practice Address - Street 1:1830 DESTINY LN
Practice Address - Street 2:SUITE 119
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1087
Practice Address - Country:US
Practice Address - Phone:270-393-9925
Practice Address - Fax:270-393-9928
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY95731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program