Provider Demographics
NPI:1720151400
Name:KEIDER, MATTHEW KELLY
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:KELLY
Last Name:KEIDER
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 1:3610 WESTGATE CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2935
Mailing Address - Country:US
Mailing Address - Phone:336-768-0480
Mailing Address - Fax:336-760-5525
Practice Address - Street 1:3610 WESTGATE CENTER CIR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2935
Practice Address - Country:US
Practice Address - Phone:336-768-0480
Practice Address - Fax:336-760-5525
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC62361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1902884943OtherNPI - NATIONAL PROVIDER
NC131195OtherUNITED CONCORDIA PROV #
NC94792OtherBCBS PROVIDER NUMBER