Provider Demographics
NPI:1881991032
Name:ANDREA MATLI SCOVILLE DDS PC
Entity type:Organization
Organization Name:ANDREA MATLI SCOVILLE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:MATLI
Authorized Official - Last Name:SCOVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-623-7121
Mailing Address - Street 1:601 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-2601
Mailing Address - Country:US
Mailing Address - Phone:580-623-7121
Mailing Address - Fax:580-623-7124
Practice Address - Street 1:601 W 2ND ST
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-2601
Practice Address - Country:US
Practice Address - Phone:580-623-7121
Practice Address - Fax:580-623-7124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK45301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty