Provider Demographics
NPI:1124230800
Name:MATTHEW P DALE DDS PA
Entity Type:Organization
Organization Name:MATTHEW P DALE DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-245-2072
Mailing Address - Street 1:13998 MAPLE KNOLL WAY # LL103
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7004
Mailing Address - Country:US
Mailing Address - Phone:763-425-2072
Mailing Address - Fax:763-425-1487
Practice Address - Street 1:13998 MAPLE KNOLL WAY # LL103
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7004
Practice Address - Country:US
Practice Address - Phone:763-425-2072
Practice Address - Fax:763-425-1487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND109801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty