Provider Demographics
NPI:1376025478
Name:MANN, MATT C
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:C
Last Name:MANN
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 1:2601 W MOCKINGBIRD LN STE 101
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-5630
Mailing Address - Country:US
Mailing Address - Phone:214-951-9710
Mailing Address - Fax:214-951-9720
Practice Address - Street 1:2601 W MOCKINGBIRD LN STE 101
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-5630
Practice Address - Country:US
Practice Address - Phone:214-951-9710
Practice Address - Fax:214-951-9720
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATP89441247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89441OtherATP LICESNSE