Provider Demographics
NPI:1336589233
Name:NETTLES, MATTHEW ALLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ALLEN
Last Name:NETTLES
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 1:25 WARD ROAD
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078
Mailing Address - Country:US
Mailing Address - Phone:803-438-1047
Mailing Address - Fax:803-438-4644
Practice Address - Street 1:25 WARD ROAD
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078
Practice Address - Country:US
Practice Address - Phone:803-438-1047
Practice Address - Fax:803-438-4644
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.8240 GD1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX8240Medicaid
SCZ16778Medicaid