Provider Demographics
NPI:1669097077
Name:MUIR, MATTHEW J
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:MUIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E STATE HIGHWAY 152 STE 113
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-5131
Mailing Address - Country:US
Mailing Address - Phone:405-353-1388
Mailing Address - Fax:
Practice Address - Street 1:1001 E STATE HIGHWAY 152 STE 113
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-5131
Practice Address - Country:US
Practice Address - Phone:405-353-1388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKT-73431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice