Provider Demographics
NPI:1669570644
Name:MATTICE, ROBERT I (DDA)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:I
Last Name:MATTICE
Suffix:
Gender:M
Credentials:DDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-1556
Mailing Address - Country:US
Mailing Address - Phone:231-723-2954
Mailing Address - Fax:231-723-3910
Practice Address - Street 1:86 MAPLE ST
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-1556
Practice Address - Country:US
Practice Address - Phone:231-723-2954
Practice Address - Fax:231-723-3910
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI88591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4006334Medicaid