Healthcare Provider Details

I. General information

NPI: 1962830455
Provider Name (Legal Business Name): MATTHEIS HARTFORD DENTAL CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 10/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W. HWY 38 SUITE #138
HARTFORD SD
57033-0757
US

IV. Provider business mailing address

PO BOX 757 304 W. HWY 38 SUITE #138
HARTFORD SD
57033-0757
US

V. Phone/Fax

Practice location:
  • Phone: 605-528-6750
  • Fax: 605-528-6752
Mailing address:
  • Phone: 605-528-6750
  • Fax: 605-528-6752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberM-733
License Number StateSD

VIII. Authorized Official

Name: DR. SCOTT MARK MATTHEIS
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 605-528-6750