Healthcare Provider Details

I. General information

NPI: 1194782375
Provider Name (Legal Business Name): IRA ROBERT MATLOFF D.D.S.,M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: I. ROBERT MATLOFF D.D.S.,M.S.

II. Dates (important events)

Enumeration Date: 04/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 N 44TH ST SUITE 10
PHOENIX AZ
85018-2730
US

IV. Provider business mailing address

4910 N 44TH ST SUITE 10
PHOENIX AZ
85018-2730
US

V. Phone/Fax

Practice location:
  • Phone: 602-840-3636
  • Fax: 602-840-7403
Mailing address:
  • Phone: 602-840-3636
  • Fax: 602-840-7403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD2386
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: