Provider Demographics
NPI:1992011647
Name:LIETO, MATTHEW C (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:C
Last Name:LIETO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 WASHINGTON ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4350
Mailing Address - Country:US
Mailing Address - Phone:616-451-2336
Mailing Address - Fax:616-222-1345
Practice Address - Street 1:255 WASHINGTON ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4350
Practice Address - Country:US
Practice Address - Phone:616-451-2336
Practice Address - Fax:616-222-1345
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010202721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice