Provider Demographics
NPI:1598174930
Name:MATT. A. PHILSON, D.D.S,P.C.
Entity Type:Organization
Organization Name:MATT. A. PHILSON, D.D.S,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:A
Authorized Official - Last Name:PHILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-543-1132
Mailing Address - Street 1:510 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2013
Mailing Address - Country:US
Mailing Address - Phone:719-543-1132
Mailing Address - Fax:719-544-0849
Practice Address - Street 1:510 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2013
Practice Address - Country:US
Practice Address - Phone:719-543-1132
Practice Address - Fax:719-544-0849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO202236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty