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General NPI Number Information
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NPI Number | 1679096523
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Entity Type | Organization
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Legal Business Name | MATTESON IMPLANT AND RECONSTRUCTIVE DENTISTRY PC.
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Dates
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Enumeration Date | 07/24/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 801 W MILWAUKEE DR
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2236
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Country | US
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Telephone | 208-664-0884
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Fax |
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Provider Business Mailing Address
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Address Line | 801 W MILWAUKEE DR
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2236
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Country | US
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Telephone | 208-664-0884
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Fax |
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Authorized Official
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Title or Position | OWNER/ PROSTHODONTIST
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Name | DR. ALVIN BRETT MATTESON
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Credential | DDS, FACP
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Telephone | 270-853-2508
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D-4027
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | D-4027
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License Number State | ID
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