Basic Information
| Provider Information | |||||||||
| NPI: | 1104945443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEST | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3501 | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995593501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436272 | ||||||||
| FaxNumber: | 9075436393 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 CHEIF EDDIE HOFFMAN HWY | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436272 | ||||||||
| FaxNumber: | 9075436393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 1176 | AK | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | DD9225 | 05 | AK | MEDICAID |