Provider Demographics
NPI:1679096523
Name:MATTESON IMPLANT AND RECONSTRUCTIVE DENTISTRY PC.
Entity Type:Organization
Organization Name:MATTESON IMPLANT AND RECONSTRUCTIVE DENTISTRY PC.
Other - Org Name:LAKEVIEW DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PROSTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:BRETT
Authorized Official - Last Name:MATTESON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FACP
Authorized Official - Phone:270-853-2508
Mailing Address - Street 1:801 W MILWAUKEE DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2236
Mailing Address - Country:US
Mailing Address - Phone:208-664-0884
Mailing Address - Fax:
Practice Address - Street 1:801 W MILWAUKEE DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2236
Practice Address - Country:US
Practice Address - Phone:208-664-0884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4027122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty