Provider Demographics
NPI:1851887145
Name:LOOMIS, MATTHEW JORDAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JORDAN
Last Name:LOOMIS
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 1:2838 N OLIVER ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2983
Mailing Address - Country:US
Mailing Address - Phone:316-978-8350
Mailing Address - Fax:
Practice Address - Street 1:2838 N OLIVER ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2983
Practice Address - Country:US
Practice Address - Phone:316-978-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist