Provider Demographics
NPI:1588958177
Name:MATTESON ORTHODONTICS MDPC
Entity type:Organization
Organization Name:MATTESON ORTHODONTICS MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEYUR
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:708-481-6086
Mailing Address - Street 1:4440 LINCOLN HWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2349
Mailing Address - Country:US
Mailing Address - Phone:708-481-6086
Mailing Address - Fax:708-481-2525
Practice Address - Street 1:4440 LINCOLN HWY
Practice Address - Street 2:SUITE 300
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2349
Practice Address - Country:US
Practice Address - Phone:708-481-6086
Practice Address - Fax:708-481-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210022321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19025814OtherHFS DENTAL PROGRAM