=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225580392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATTHEW T. ERTL, D.M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2016
-----------------------------------------------------
Last Update Date | 03/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1978 HENDERSONVILLE RD SUITE 30
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28803-7766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-687-7271
-----------------------------------------------------
Fax | 828-475-1331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 398 WEBB COVE RD
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28804-1933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-687-7271
-----------------------------------------------------
Fax | 828-475-1331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/PRESIDENT
-----------------------------------------------------
Name | DR. MATTHEW THOMAS ERTL
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 828-687-7271
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 8680
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------