Provider Demographics
NPI:1366672875
Name:WHITESIDES, MATTHEW DAVID (DDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:WHITESIDES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-350-4606
Mailing Address - Fax:970-350-4645
Practice Address - Street 1:100 N 11TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-2011
Practice Address - Country:US
Practice Address - Phone:970-313-0353
Practice Address - Fax:970-351-7075
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9976122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65000846Medicaid