Provider Demographics
NPI:1992240774
Name:ROBERT I. MATTICE, DDS, PC
Entity type:Organization
Organization Name:ROBERT I. MATTICE, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTICE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-723-2954
Mailing Address - Street 1:422 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-1504
Mailing Address - Country:US
Mailing Address - Phone:231-723-2954
Mailing Address - Fax:231-723-3910
Practice Address - Street 1:422 1ST ST
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-1504
Practice Address - Country:US
Practice Address - Phone:231-723-2954
Practice Address - Fax:231-723-3910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI8859122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty