Provider Demographics
NPI:1720222607
Name:MCDONOUGH, MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:MCDONOUGH
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 1:1501 HILLIARD ROME RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-9544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 HILLIARD ROME RD
Practice Address - Street 2:SUITE E
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-9544
Practice Address - Country:US
Practice Address - Phone:614-398-3798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAFM17683621223S0112X
OH300240151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery