Healthcare Provider Details

I. General information

NPI: 1194020719
Provider Name (Legal Business Name): NICHOLAS RUDOLPH MATACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 E 4TH ST
DULUTH MN
55805-1935
US

IV. Provider business mailing address

1415 MISSISSIPPI AVE
DULUTH MN
55811
US

V. Phone/Fax

Practice location:
  • Phone: 218-727-1448
  • Fax:
Mailing address:
  • Phone: 218-310-5902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD13811
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: