Provider Demographics
NPI:1578585691
Name:CROCO, MATTHEW AT (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:AT
Last Name:CROCO
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 CORAL CT STE 2
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2837
Mailing Address - Country:US
Mailing Address - Phone:319-545-7600
Mailing Address - Fax:319-545-7640
Practice Address - Street 1:2451 CORAL CT STE 2
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2837
Practice Address - Country:US
Practice Address - Phone:319-545-7600
Practice Address - Fax:319-545-7640
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0463018Medicaid