Provider Demographics
NPI:1811564925
Name:FERRIN, MATTHEW
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:FERRIN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MATT
Other - Middle Name:
Other - Last Name:FERRIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2180 COALFAX CT
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-1747
Mailing Address - Country:US
Mailing Address - Phone:805-279-2072
Mailing Address - Fax:
Practice Address - Street 1:2180 COALFAX CT
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-1747
Practice Address - Country:US
Practice Address - Phone:805-279-2072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2024-05-13
Deactivation Date:2024-04-03
Deactivation Code:
Reactivation Date:2024-04-17
Provider Licenses
StateLicense IDTaxonomies
390200000X
CADDS1093441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
905232463OtherUCLA