Healthcare Provider Details

I. General information

NPI: 1437740313
Provider Name (Legal Business Name): MATTSON DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 E PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-8369
US

IV. Provider business mailing address

1151 E PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-8369
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-5980
  • Fax:
Mailing address:
  • Phone: 616-949-5980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CARMEN BOLLINGER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 616-706-7637