Provider Demographics
NPI:1235958067
Name:MATLOCK, THERESA LYNN (RDH)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MERCURY VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-8955
Mailing Address - Country:US
Mailing Address - Phone:970-335-2422
Mailing Address - Fax:
Practice Address - Street 1:691 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2802
Practice Address - Country:US
Practice Address - Phone:970-565-7946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002024081124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist