Provider Demographics
NPI:1578910600
Name:TISSUE, MATTHEW (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:TISSUE
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 1:501 LAPEER AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1203
Mailing Address - Country:US
Mailing Address - Phone:989-759-6464
Mailing Address - Fax:989-399-8233
Practice Address - Street 1:6800 NEWARK RD
Practice Address - Street 2:STE 400
Practice Address - City:IMLAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48444-9656
Practice Address - Country:US
Practice Address - Phone:810-721-7453
Practice Address - Fax:810-721-7454
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice