=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255792750
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IAN MATZKOWITZ DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2016
-----------------------------------------------------
Last Update Date | 01/28/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15228 W BAKER AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80228-5501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-692-3478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15228 W BAKER AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80228-5501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-692-3478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DEN.00203272
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------