Healthcare Provider Details

I. General information

NPI: 1679096523
Provider Name (Legal Business Name): MATTESON IMPLANT AND RECONSTRUCTIVE DENTISTRY PC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MILWAUKEE DR
COEUR D ALENE ID
83814-2236
US

IV. Provider business mailing address

801 W MILWAUKEE DR
COEUR D ALENE ID
83814-2236
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-0884
  • Fax:
Mailing address:
  • Phone: 208-664-0884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-4027
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD-4027
License Number StateID

VIII. Authorized Official

Name: DR. ALVIN BRETT MATTESON
Title or Position: OWNER/ PROSTHODONTIST
Credential: DDS, FACP
Phone: 270-853-2508