Healthcare Provider Details

I. General information

NPI: 1164555629
Provider Name (Legal Business Name): MATTHEW LEO MOLITOR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1759 OAK AVE
DAVIS CA
95616-1004
US

IV. Provider business mailing address

1759 OAK AVE
DAVIS CA
95616-1004
US

V. Phone/Fax

Practice location:
  • Phone: 530-758-6420
  • Fax: 530-758-3856
Mailing address:
  • Phone: 530-758-6420
  • Fax: 530-758-3856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number41653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: