Provider Demographics
NPI:1588809974
Name:MATT HOIDAL, DDS, MS, PC
Entity Type:Organization
Organization Name:MATT HOIDAL, DDS, MS, PC
Other - Org Name:LAKE OSWEGO PERIODONTICS AND IMPLANT DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HOIDAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:503-635-3584
Mailing Address - Street 1:300 OSWEGO POINTE DR
Mailing Address - Street 2:STE 106
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3254
Mailing Address - Country:US
Mailing Address - Phone:503-635-3584
Mailing Address - Fax:503-635-6813
Practice Address - Street 1:300 OSWEGO POINTE DR
Practice Address - Street 2:STE 106
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3254
Practice Address - Country:US
Practice Address - Phone:503-635-3584
Practice Address - Fax:503-635-6813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-13
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9075261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental