=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477292449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KORTNI MATTESON DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2022
-----------------------------------------------------
Last Update Date | 05/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4710 N M 37 HWY
-----------------------------------------------------
City | MIDDLEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49333-8351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-760-1229
-----------------------------------------------------
Fax | 269-795-8881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4710 N M 37 HWY
-----------------------------------------------------
City | MIDDLEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49333-8351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-760-1229
-----------------------------------------------------
Fax | 269-795-8881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KORTNI MATTESON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 269-760-1229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------