Provider Demographics
NPI:1982776449
Name:VAILLANT, MATTHEW JONATHON (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JONATHON
Last Name:VAILLANT
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 1:16699 FARRAGO TRL
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-7830
Mailing Address - Country:US
Mailing Address - Phone:952-997-7123
Mailing Address - Fax:
Practice Address - Street 1:421 W 4TH ST
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2555
Practice Address - Country:US
Practice Address - Phone:651-388-6709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND115241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice