Provider Demographics
NPI:1881842672
Name:MATC DENTAL HYGIENE CLINIC
Entity type:Organization
Organization Name:MATC DENTAL HYGIENE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:E.
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GOETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:608-258-2470
Mailing Address - Street 1:211 N CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-2211
Mailing Address - Country:US
Mailing Address - Phone:608-258-2400
Mailing Address - Fax:
Practice Address - Street 1:211 N CARROLL ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2211
Practice Address - Country:US
Practice Address - Phone:608-258-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38382500Medicaid