Healthcare Provider Details

I. General information

NPI: 1881842672
Provider Name (Legal Business Name): MATC DENTAL HYGIENE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N CARROLL ST
MADISON WI
53703-2211
US

IV. Provider business mailing address

211 N CARROLL ST
MADISON WI
53703-2211
US

V. Phone/Fax

Practice location:
  • Phone: 608-258-2400
  • Fax:
Mailing address:
  • Phone: 608-258-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: E. LYNN GOETSCH
Title or Position: CLINIC SUPERVISOR
Credential: RDH
Phone: 608-258-2470