Provider Demographics
NPI:1699782854
Name:KOOYMAN, MATTHEW L (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:KOOYMAN
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 1:1500 W CAYUSE CREEK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4757
Mailing Address - Country:US
Mailing Address - Phone:208-884-8858
Mailing Address - Fax:208-884-8915
Practice Address - Street 1:1500 W CAYUSE CREEK DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-4757
Practice Address - Country:US
Practice Address - Phone:508-884-8858
Practice Address - Fax:208-884-8915
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-35651223G0001X
ILD-3565122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist