Healthcare Provider Details

I. General information

NPI: 1457571705
Provider Name (Legal Business Name): SCOTT MARK MATTHEIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

304 W. HWY 38 STE. 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 Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM-733
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: