Healthcare Provider Details

I. General information

NPI: 1386653111
Provider Name (Legal Business Name): MATT A MLSNA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N ALPINE RD
ROCKFORD IL
61107-2262
US

IV. Provider business mailing address

1259 KRUPKE RD
CALEDONIA IL
61011-9567
US

V. Phone/Fax

Practice location:
  • Phone: 815-397-4280
  • Fax: 815-484-2436
Mailing address:
  • Phone: 815-765-1989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: