MEDICARE: DR. MATTHEW JOHN THIEL 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	30021600	OH

General Provider Information

NPI Number	:	1386798684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW JOHN THIEL DDS

Provider Business Mailing Address
First Line	:	6503 FRANK AVE NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-7265
Country	:	US
Telephone Number	:	330-244-9030
Fax Number	:	330-244-9099

Provider Business Practice Location Address
First Line	:	6503 FRANK AVE NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-7265
Country	:	US
Telephone Number	:	330-244-9030
Fax Number	:	330-244-9099

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

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/08/2007

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