Provider Demographics
NPI:1750642039
Name:MATTINGLY, EMILY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:A
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-3673
Mailing Address - Country:US
Mailing Address - Phone:660-646-3802
Mailing Address - Fax:660-646-3887
Practice Address - Street 1:850 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-3673
Practice Address - Country:US
Practice Address - Phone:660-646-3802
Practice Address - Fax:660-646-3887
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120158081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice