NPIMap

Individual provider Active NPI

Nicole Mathew, DT

  • Dental Therapist
  • Minneapolis, MN
National Provider Identifier
1073013322
Registry record updated Feb 13, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dental TherapistTaxonomy code 125J00000X
License
DT96 Issued in MN
Practice address
636 Broadway St NE
Minneapolis, MN 55413-2164
Phone
(612) 746-1530
Fax
(612) 746-1531
NPI assigned
Feb 13, 2018
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 13, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Therapist 125J00000X DT96 MN Primary

Addresses

Primary practice location

636 Broadway St NE
Minneapolis, MN 55413-2164

Mailing address

636 Broadway St NE
Minneapolis, MN 55413-2164
Phone (612) 746-1530

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
DT96MNMDDental Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
Children'S Dental Services Past Accepting new patients
Childrens Dental Services Inc Past Accepting new patients

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1518480000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1518480000000",
    "number": "1073013322",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "636 BROADWAY ST NE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554132164",
            "telephone_number": "612-746-1530",
            "fax_number": "612-746-1531"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "636 BROADWAY ST NE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554132164",
            "telephone_number": "612-746-1530",
            "fax_number": "612-746-1531"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MATHEW",
        "first_name": "NICOLE",
        "credential": "DT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-02-13",
        "last_updated": "2018-02-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "125J00000X",
            "taxonomy_group": "",
            "desc": "Dental Therapist",
            "state": "MN",
            "license": "DT96",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Minneapolis, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 13, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.