Active NPI
Matthew John Phan, DDS
- Dentist
- Roselle, IL
National Provider Identifier
1164944146
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 019.032245
- Practice address
- 21 W Irving Park Rd
Roselle, IL 60172-1117 - Phone
- (805) 813-9567
- NPI assigned
- Jul 12, 2017
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 019.032245 | IL | Primary |
Addresses
Primary practice location
21 W Irving Park Rd
Roselle, IL 60172-1117
Mailing address
21 W Irving Park Rd
Roselle, IL 60172-1117
Phone (805) 813-9567
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)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019.032245 | IL | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1499817600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1721260800000",
"number": "1164944146",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "21 W IRVING PARK RD",
"city": "ROSELLE",
"state": "IL",
"postal_code": "601721117",
"telephone_number": "805-813-9567"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "21 W IRVING PARK RD",
"city": "ROSELLE",
"state": "IL",
"postal_code": "601721117",
"telephone_number": "805-813-9567"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PHAN",
"first_name": "MATTHEW",
"middle_name": "JOHN",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2017-07-12",
"last_updated": "2024-07-18",
"certification_date": "2024-07-18",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IL",
"license": "019.032245",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Roselle, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.