Provider Demographics
NPI:1578891693
Name:MATTILA, DUSTIN PHILIP (DC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:PHILIP
Last Name:MATTILA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 NORTH MICHIGAN AVENUE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-3103
Mailing Address - Country:US
Mailing Address - Phone:517-552-8500
Mailing Address - Fax:517-552-8594
Practice Address - Street 1:1455 NORTH MICHIGAN AVENUE
Practice Address - Street 2:SUITE 700
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-3103
Practice Address - Country:US
Practice Address - Phone:517-552-8500
Practice Address - Fax:517-552-8594
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5293111N00000X
MI2301009748111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor