Healthcare Provider Details

I. General information

NPI: 1124976584
Provider Name (Legal Business Name): DANNIE MATHEW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 3RD ST SW STE 300
ROCHESTER MN
55902-3022
US

IV. Provider business mailing address

18 3RD ST SW STE 300
ROCHESTER MN
55902-3022
US

V. Phone/Fax

Practice location:
  • Phone: 507-258-5260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD15532
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: