Provider Demographics
NPI:1508433160
Name:INTEGRATED DENTAL ARTS PLLC
Entity Type:Organization
Organization Name:INTEGRATED DENTAL ARTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHESON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-351-1001
Mailing Address - Street 1:7251 W 20TH ST BLDG H
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4625
Mailing Address - Country:US
Mailing Address - Phone:970-281-5972
Mailing Address - Fax:
Practice Address - Street 1:7251 W 20TH ST BLDG H
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4625
Practice Address - Country:US
Practice Address - Phone:970-281-5972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty