=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508433160
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED DENTAL ARTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2021
-----------------------------------------------------
Last Update Date | 06/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7251 W 20TH ST BLDG H
-----------------------------------------------------
City | GREELEY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80634-4625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-281-5972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7251 W 20TH ST BLDG H
-----------------------------------------------------
City | GREELEY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80634-4625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-281-5972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TODD MATHESON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 208-351-1001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------