Provider Demographics
NPI:1710008388
Name:KNUTSON, MATTHEW RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RICHARD
Last Name:KNUTSON
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 1:1714 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069
Mailing Address - Country:US
Mailing Address - Phone:605-624-6291
Mailing Address - Fax:605-624-9488
Practice Address - Street 1:1714 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069
Practice Address - Country:US
Practice Address - Phone:605-624-6291
Practice Address - Fax:605-624-9488
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM9691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7809990Medicaid