MEDICARE: DR. MATTHEW THOMAS COLAIZY DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	11657	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	648375500	OTHER	MN	MEDICAL ASSISTANCE, GMAC

General Provider Information

NPI Number	:	1215146659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW THOMAS COLAIZY DDS

Provider Business Mailing Address
First Line	:	2042 SAINT CLAIR AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1650
Country	:	US
Telephone Number	:	651-298-0024
Fax Number	:	651-695-2333

Provider Business Practice Location Address
First Line	:	2042 SAINT CLAIR AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1650
Country	:	US
Telephone Number	:	651-298-0024
Fax Number	:	651-695-2333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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