=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437162203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATT M. ANZELC DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3145 7TH AVE E
-----------------------------------------------------
City | HIBBING
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55746-2625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-263-8928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3145 7TH AVE E
-----------------------------------------------------
City | HIBBING
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55746-2625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-263-8928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/PRESIDENT
-----------------------------------------------------
Name | DR. MATT M ANZELC
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 218-263-8929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 8045
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------