Provider Demographics
NPI:1194020719
Name:MATACK, NICHOLAS RUDOLPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:RUDOLPH
Last Name:MATACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811
Mailing Address - Country:US
Mailing Address - Phone:218-310-5902
Mailing Address - Fax:
Practice Address - Street 1:421 E 4TH ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1935
Practice Address - Country:US
Practice Address - Phone:218-727-1448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13811122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist