Provider Demographics
NPI:1326545450
Name:BEAN, MATTHEW THOMAS
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BEAN
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 1:1801 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-2186
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:271 FORT RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:GOODFELLOW AFB
Practice Address - State:TX
Practice Address - Zip Code:76908-4901
Practice Address - Country:US
Practice Address - Phone:325-654-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI1001839-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program