Provider Demographics
NPI:1568083772
Name:MATOS, KOLVER (DDS)
Entity Type:Individual
Prefix:
First Name:KOLVER
Middle Name:
Last Name:MATOS
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 1:3757 E GRANGE AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-2363
Mailing Address - Country:US
Mailing Address - Phone:815-762-5655
Mailing Address - Fax:
Practice Address - Street 1:N112W16286 MEQUON RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-3306
Practice Address - Country:US
Practice Address - Phone:262-725-4085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002358-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice