MEDICARE: DR. BRUCE ALLAN MATIS DDS, MSD

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	12009604A	IN

General Provider Information

NPI Number	:	1790799328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE ALLAN MATIS DDS, MSD

Provider Business Mailing Address
First Line	:	7141 CREEKWOOD EST
Second Line	:
City	:	BROWNSBURG
State	:	IN
Zip	:	46112-8425
Country	:	US
Telephone Number	:	317-852-2139
Fax Number	:	317-852-3162

Provider Business Practice Location Address
First Line	:	1121 W MICHIGAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-5211
Country	:	US
Telephone Number	:	317-278-1099
Fax Number	:	317-278-4900

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

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	07/08/2007

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