Provider Demographics
NPI:1760679401
Name:MATTHEW THERIAC, D.D.S. LLC
Entity Type:Organization
Organization Name:MATTHEW THERIAC, D.D.S. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:THERIAC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:660-385-3623
Mailing Address - Street 1:905 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-2016
Mailing Address - Country:US
Mailing Address - Phone:660-385-3623
Mailing Address - Fax:
Practice Address - Street 1:905 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-2016
Practice Address - Country:US
Practice Address - Phone:660-385-3623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO15187302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization