Provider Demographics
NPI:1649416710
Name:PRESCOTT, MATTHEW STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:PRESCOTT
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 1:1640 N. WELLS STREET
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:312-642-4218
Mailing Address - Fax:312-642-6418
Practice Address - Street 1:1640 N. WELLS STREET
Practice Address - Street 2:SUITE 205
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:312-642-4218
Practice Address - Fax:312-642-6418
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0228951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice