Provider Demographics
NPI:1639514672
Name:MYERS, MATTHEW E (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:E
Last Name:MYERS
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 1:3162 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8450
Mailing Address - Country:US
Mailing Address - Phone:541-779-7799
Mailing Address - Fax:541-779-7810
Practice Address - Street 1:3162 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-779-7799
Practice Address - Fax:541-779-7810
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106451223S0112X
AZBD6377712-13921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500727747Medicaid