Healthcare Provider Details

I. General information

NPI: 1750747077
Provider Name (Legal Business Name): MATT MCCOY D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 MERLIN DR
IDAHO FALLS ID
83404-7430
US

IV. Provider business mailing address

596 TAYLOR LN
CHUBBUCK ID
83202-2380
US

V. Phone/Fax

Practice location:
  • Phone: 801-440-6849
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD4719
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: