Provider Demographics
NPI:1235592734
Name:MCDONALD, MATTHEW JOHN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 CRESTON PARK DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1119
Mailing Address - Country:US
Mailing Address - Phone:608-755-1082
Mailing Address - Fax:
Practice Address - Street 1:1336 CRESTON PARK DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1119
Practice Address - Country:US
Practice Address - Phone:608-755-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001311-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist