Provider Demographics
NPI:1790190619
Name:CALLISTER, MATTHEW S (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:CALLISTER
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 1:1172 E 100 N
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-1667
Mailing Address - Country:US
Mailing Address - Phone:801-465-3691
Mailing Address - Fax:801-465-3913
Practice Address - Street 1:1172 E 100 N
Practice Address - Street 2:SUITE 6
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1667
Practice Address - Country:US
Practice Address - Phone:801-465-3691
Practice Address - Fax:801-465-3913
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9035046122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist