Provider Demographics
NPI:1205380888
Name:ANDREW W MATTSON DDS LLC
Entity Type:Organization
Organization Name:ANDREW W MATTSON DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:W
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-758-0536
Mailing Address - Street 1:55 ROCHE WAY
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6214
Mailing Address - Country:US
Mailing Address - Phone:330-758-0536
Mailing Address - Fax:330-758-0854
Practice Address - Street 1:55 ROCHE WAY
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6214
Practice Address - Country:US
Practice Address - Phone:330-758-0536
Practice Address - Fax:330-758-0854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300245041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty