Provider Demographics
NPI:1285613240
Name:HLAVACEK, MATTHEW R (MD, DDS)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:R
Last Name:HLAVACEK
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 NE WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5594
Mailing Address - Country:US
Mailing Address - Phone:816-524-4334
Mailing Address - Fax:816-524-4399
Practice Address - Street 1:1208 NE WINDSOR DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-5594
Practice Address - Country:US
Practice Address - Phone:816-524-4334
Practice Address - Fax:816-524-4399
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0160831223S0112X, 122300000X
MO2005027155208D00000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204017107Medicaid
MO404017105Medicaid
MO404017105Medicaid
MO204017107Medicaid
MOU05567Medicare UPIN