MEDICARE: MATTSON DENTAL, PLLC

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	332BC3200X	Customized Equipment (DME)
2	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437740313
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATTSON DENTAL, PLLC

Provider Business Mailing Address
First Line	:	1151 E PARIS AVE SE STE 100
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-8369
Country	:	US
Telephone Number	:	616-949-5980
Fax Number	:

Provider Business Practice Location Address
First Line	:	1151 E PARIS AVE SE STE 100
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-8369
Country	:	US
Telephone Number	:	616-949-5980
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	CARMEN BOLLINGER
Credential	:
Telephone Number	:	616-706-7637

Provider Enumeration Date	:	02/02/2021
Last Update Date	:	07/18/2024

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