Provider Demographics
NPI:1245366186
Name:MATTSON, GARY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:MATTSON
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 1:113 LITCHFIELD AVE SE
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3628
Mailing Address - Country:US
Mailing Address - Phone:320-235-9551
Mailing Address - Fax:320-235-6786
Practice Address - Street 1:113 LITCHFIELD AVE SE
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3628
Practice Address - Country:US
Practice Address - Phone:320-235-9551
Practice Address - Fax:320-235-6786
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN90831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice