Provider Demographics
NPI:1154561926
Name:HENRY, MATTHEW (DDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:HENRY
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 1:39375 RIDGE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEVERANCE
Mailing Address - State:CO
Mailing Address - Zip Code:80610
Mailing Address - Country:US
Mailing Address - Phone:970-674-0101
Mailing Address - Fax:
Practice Address - Street 1:1439 STILLWATER AVE STE 7
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7367
Practice Address - Country:US
Practice Address - Phone:307-778-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-05
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1290122300000X
WY12451223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist