Provider Demographics
NPI:1720200165
Name:MATTINGLY, MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MATTINGLY
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 1:3255 LYNDALE AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3647
Mailing Address - Country:US
Mailing Address - Phone:612-822-8968
Mailing Address - Fax:
Practice Address - Street 1:3255 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3647
Practice Address - Country:US
Practice Address - Phone:612-822-8968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN99981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice