Provider Demographics
NPI:1437105764
Name:MATTIE, MICHAEL EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:MATTIE
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 1:219 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-3324
Mailing Address - Country:US
Mailing Address - Phone:203-239-9427
Mailing Address - Fax:203-239-9427
Practice Address - Street 1:219 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-3324
Practice Address - Country:US
Practice Address - Phone:203-239-9427
Practice Address - Fax:203-239-9427
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT76521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice