Provider Demographics
NPI:1629289541
Name:MACK, MATTHEW P (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:P
Last Name:MACK
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 1:13577 CHURCH VIEW CT
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147
Mailing Address - Country:US
Mailing Address - Phone:614-834-4813
Mailing Address - Fax:
Practice Address - Street 1:1420 DICKERSON ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1844
Practice Address - Country:US
Practice Address - Phone:740-344-9155
Practice Address - Fax:740-344-5668
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300214741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice