Provider Demographics
NPI:1497098255
Name:MIDTLING, MATTHEW JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JAMES
Last Name:MIDTLING
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1910 NORHARDT DR
Mailing Address - Street 2:#105
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5089
Mailing Address - Country:US
Mailing Address - Phone:651-402-6593
Mailing Address - Fax:
Practice Address - Street 1:840 N. 87TH STREETH
Practice Address - Street 2:SARGEANT HEALTH CENTER
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-805-5760
Practice Address - Fax:414-259-9115
Is Sole Proprietor?:No
Enumeration Date:2013-03-30
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI72691223S0112X, 1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1497098255Medicaid