Provider Demographics
NPI:1629873898
Name:IDEAL DENTAL INDIAN LAND PC
Entity type:Organization
Organization Name:IDEAL DENTAL INDIAN LAND PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DDOAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-829-0119
Mailing Address - Street 1:PO BOX 840925
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0925
Mailing Address - Country:US
Mailing Address - Phone:972-361-0600
Mailing Address - Fax:
Practice Address - Street 1:2089 PARKWAY DR STE 102
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-8089
Practice Address - Country:US
Practice Address - Phone:803-829-0119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-13
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty