Provider Demographics
NPI:1881798510
Name:MATTOCKS, MARK STEVEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:MATTOCKS
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 1:2619 16TH AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405
Mailing Address - Country:US
Mailing Address - Phone:406-727-8440
Mailing Address - Fax:
Practice Address - Street 1:2619 16TH AVE SOUTH
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405
Practice Address - Country:US
Practice Address - Phone:406-727-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT15241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice