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General NPI Number Information
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NPI Number | 1194020719
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Entity Type | Individual
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Provider Name | NICHOLAS RUDOLPH MATACK DDS
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Gender | Male
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Dates
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Enumeration Date | 01/12/2011
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Last Update Date | 12/20/2017
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Provider Practice Location Address
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Address Line | 421 E 4TH ST
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City | DULUTH
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State | MN
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Zip | 55805-1935
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Country | US
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Telephone | 218-727-1448
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Fax |
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Provider Business Mailing Address
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Address Line | 1415 MISSISSIPPI AVE
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City | DULUTH
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State | MN
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Zip | 55811
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Country | US
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Telephone | 218-310-5902
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D13811
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License Number State | MN
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