Provider Demographics
NPI:1487215422
Name:SMILANICH, MATTHEW THOMAS
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:SMILANICH
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 1:2460 FINGER RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-4210
Mailing Address - Country:US
Mailing Address - Phone:920-469-8484
Mailing Address - Fax:
Practice Address - Street 1:2460 FINGER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-4210
Practice Address - Country:US
Practice Address - Phone:920-469-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002132-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist