Provider Demographics
NPI:1629205794
Name:MILLIGAN, MATTHEW J (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:MILLIGAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3144
Mailing Address - Country:US
Mailing Address - Phone:618-549-0208
Mailing Address - Fax:618-549-0182
Practice Address - Street 1:1366 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3144
Practice Address - Country:US
Practice Address - Phone:618-549-0208
Practice Address - Fax:618-549-0182
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027943122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist