=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912151960
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW EUGENE MANSFIELD DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2008
-----------------------------------------------------
Last Update Date | 11/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2729 STATE ROUTE 76 WEST
-----------------------------------------------------
City | WILLOW SPRINGS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-469-2030
-----------------------------------------------------
Fax | 417-469-5085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2
-----------------------------------------------------
City | WILLOW SPRINGS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-469-2030
-----------------------------------------------------
Fax | 417-469-5085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2000157567
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------