Healthcare Provider Details

I. General information

NPI: 1255650529
Provider Name (Legal Business Name): MATTHEW SCOTT STANDRIDGE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SOUTHTOWNE DR
POTOSI MO
63664-5729
US

IV. Provider business mailing address

420 W 15TH AVE
EMPORIA KS
66801-5367
US

V. Phone/Fax

Practice location:
  • Phone: 573-438-8401
  • Fax:
Mailing address:
  • Phone: 620-342-4864
  • Fax: 620-342-7790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number2010016150
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number60776
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60776
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: