Healthcare Provider Details

I. General information

NPI: 1104313238
Provider Name (Legal Business Name): MATTHEW BLAKE SHERWOOD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2018
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W RAILROAD AVE
PLAINS MT
59859-7763
US

IV. Provider business mailing address

PO BOX 837
PLAINS MT
59859-0837
US

V. Phone/Fax

Practice location:
  • Phone: 316-737-7590
  • Fax:
Mailing address:
  • Phone: 406-215-4705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN-DEN-LIC-20163
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: