MEDICARE: DR. BRUCE JAMES MATHIASON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D8569	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2420L8000	OTHER	MN	MEDICALASSISTANCE

General Provider Information

NPI Number	:	1366405722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE JAMES MATHIASON DDS

Provider Business Mailing Address
First Line	:	400 7TH ST
Second Line	:
City	:	WALNUT GROVE
State	:	MN
Zip	:	56180-9203
Country	:	US
Telephone Number	:	507-859-2179
Fax Number	:	507-859-2178

Provider Business Practice Location Address
First Line	:	400 7TH ST
Second Line	:
City	:	WALNUT GROVE
State	:	MN
Zip	:	56180-9203
Country	:	US
Telephone Number	:	507-859-2179
Fax Number	:	507-859-2178

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	07/08/2007

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