Provider Demographics
NPI:1619102647
Name:RASCHE, MATTHEW LAWRENCE (DDS MSD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LAWRENCE
Last Name:RASCHE
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 S AUTO MALL RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5430
Mailing Address - Country:US
Mailing Address - Phone:812-333-5437
Mailing Address - Fax:812-333-6305
Practice Address - Street 1:828 S AUTO MALL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5430
Practice Address - Country:US
Practice Address - Phone:812-333-5437
Practice Address - Fax:812-333-6305
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011284A122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201019080AMedicaid