Provider Demographics
NPI:1285130799
Name:MATUSIEWICZ, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MATUSIEWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 43RD ST NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-5847
Mailing Address - Country:US
Mailing Address - Phone:507-287-8320
Mailing Address - Fax:507-281-8757
Practice Address - Street 1:3000 43RD ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-5847
Practice Address - Country:US
Practice Address - Phone:507-287-8320
Practice Address - Fax:507-281-8757
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist