Provider Demographics
NPI:1598850273
Name:MATTY, CHARLES W (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:W
Last Name:MATTY
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 1:1855 DAIMLER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112
Mailing Address - Country:US
Mailing Address - Phone:815-397-7717
Mailing Address - Fax:815-397-7719
Practice Address - Street 1:1855 DAIMLER RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112
Practice Address - Country:US
Practice Address - Phone:815-397-7717
Practice Address - Fax:815-397-7719
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice