Provider Demographics
NPI:1194074237
Name:VOGT, MATILDE JEANETTE (RDH)
Entity type:Individual
Prefix:
First Name:MATILDE
Middle Name:JEANETTE
Last Name:VOGT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:
Other - Last Name:PEREZ-VOGT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:4500 CAMBON ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-1226
Mailing Address - Country:US
Mailing Address - Phone:541-515-9101
Mailing Address - Fax:
Practice Address - Street 1:1400 MILL ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4259
Practice Address - Country:US
Practice Address - Phone:541-344-8302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6326124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist