Provider Demographics
NPI:1215146659
Name:COLAIZY, MATTHEW THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:COLAIZY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2042 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1650
Mailing Address - Country:US
Mailing Address - Phone:651-298-0024
Mailing Address - Fax:651-695-2333
Practice Address - Street 1:2042 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1650
Practice Address - Country:US
Practice Address - Phone:651-298-0024
Practice Address - Fax:651-695-2333
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11657122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN648375500OtherMEDICAL ASSISTANCE, GMAC