Provider Demographics
NPI:1558509653
Name:LACKNEY, MATTHEW W (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:W
Last Name:LACKNEY
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 1:775 WAUKEGAN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4342
Mailing Address - Country:US
Mailing Address - Phone:847-267-9440
Mailing Address - Fax:800-434-7113
Practice Address - Street 1:775 WAUKEGAN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4342
Practice Address - Country:US
Practice Address - Phone:847-267-9440
Practice Address - Fax:800-434-7113
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.019889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist