Provider Demographics
NPI:1295916419
Name:AGNEW, MATT R (DMD)
Entity type:Individual
Prefix:MR
First Name:MATT
Middle Name:R
Last Name:AGNEW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2901 W. BELTLINE HWY.
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-4226
Mailing Address - Country:US
Mailing Address - Phone:608-443-5500
Mailing Address - Fax:608-441-1981
Practice Address - Street 1:1270 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1930
Practice Address - Country:US
Practice Address - Phone:608-443-5482
Practice Address - Fax:608-837-9134
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6179-151223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33815700Medicaid