Active NPI
Nicholas Rudolph Matack, DDS
- Dentist
- Duluth, MN
National Provider Identifier
1194020719
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- D13811
- Practice address
- 421 E 4TH St
Duluth, MN 55805-1935 - Phone
- (218) 727-1448
- NPI assigned
- Jan 12, 2011
- 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 | D13811 | MN | Primary |
Addresses
Primary practice location
421 E 4TH St
Duluth, MN 55805-1935
Mailing address
1415 Mississippi Ave
Duluth, MN 55811
Phone (218) 310-5902
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 |
|---|---|---|---|
| D13811 | MN | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Chart and Mohs Dentistry P.a. | Dentist | Past | Accepting new patients |
Organizations & group practices 1
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.
-
- Dentist
- Duluth, MN
- NPI 1326214164
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1294790400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1513728000000",
"number": "1194020719",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1415 MISSISSIPPI AVE",
"city": "DULUTH",
"state": "MN",
"postal_code": "55811",
"telephone_number": "218-310-5902"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "421 E 4TH ST",
"city": "DULUTH",
"state": "MN",
"postal_code": "558051935",
"telephone_number": "218-727-1448"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MATACK",
"first_name": "NICHOLAS",
"middle_name": "RUDOLPH",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2011-01-12",
"last_updated": "2017-12-20",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MN",
"license": "D13811",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Duluth, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 20, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.