=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750747077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATT MCCOY D.D.S., M.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2016
-----------------------------------------------------
Last Update Date | 01/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3411 MERLIN DR
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-7430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-440-6849
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 596 TAYLOR LN
-----------------------------------------------------
City | CHUBBUCK
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83202-2380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | D4719
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------