Provider Demographics
NPI:1891173282
Name:BLACK, MATTHEW KIMBALL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:KIMBALL
Last Name:BLACK
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 1:512 N YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7839
Mailing Address - Country:US
Mailing Address - Phone:509-783-7600
Mailing Address - Fax:509-783-0774
Practice Address - Street 1:512 N YOUNG ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7839
Practice Address - Country:US
Practice Address - Phone:509-783-7600
Practice Address - Fax:509-783-0774
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WA610252961223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program