Provider Demographics
NPI:1194780502
Name:VILLAIRE, MATTHEW JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:VILLAIRE
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 1:23880 FAIRMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-2206
Mailing Address - Country:US
Mailing Address - Phone:216-381-2010
Mailing Address - Fax:
Practice Address - Street 1:5001 MAYFIELD RD
Practice Address - Street 2:SUITE #112
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2602
Practice Address - Country:US
Practice Address - Phone:216-381-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300182981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2055707Medicaid