Provider Demographics
NPI:1063570323
Name:ROBERT S MATTINGLY DMD
Entity type:Organization
Organization Name:ROBERT S MATTINGLY DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:812-738-0108
Mailing Address - Street 1:127 S CAPITOL AVE
Mailing Address - Street 2:PO BOX 387
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-1103
Mailing Address - Country:US
Mailing Address - Phone:812-738-0108
Mailing Address - Fax:812-738-7758
Practice Address - Street 1:127 S CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-1103
Practice Address - Country:US
Practice Address - Phone:812-738-0108
Practice Address - Fax:812-738-7758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200142380Medicare ID - Type Unspecified