Provider Demographics
NPI:1154570448
Name:MAIN STREET DENTAL, LLC
Entity type:Organization
Organization Name:MAIN STREET DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MATHES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:620-672-9922
Mailing Address - Street 1:603 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-2630
Mailing Address - Country:US
Mailing Address - Phone:620-672-9922
Mailing Address - Fax:620-672-9966
Practice Address - Street 1:603 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-2630
Practice Address - Country:US
Practice Address - Phone:620-672-9922
Practice Address - Fax:620-672-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5971122300000X
KS60593122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS116863OtherBLUE CROSS & BLUE SHEILD
KS100222640AMedicaid