=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518578822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JOSEPH MICHELOTTI DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2020
-----------------------------------------------------
Last Update Date | 08/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 740 HELENA AVE
-----------------------------------------------------
City | HELENA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59601-3627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-442-7980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 740 HELENA AVE
-----------------------------------------------------
City | HELENA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59601-3627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-442-7980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN-DEN-LIC-19394
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 19394
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------