=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962735035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JAMES COON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2009
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1617 17TH AVE
-----------------------------------------------------
City | CENTRAL CITY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68826-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-946-3841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1415 SAGE ST
-----------------------------------------------------
City | GERING
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69341-3229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-436-3491
-----------------------------------------------------
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 | 6759
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------