# MAIN STREET DENTAL, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1154570448
- **Authorized official:** DR. JOHN D. MATHES DDS (OWNER)
- **Authorized official phone:** (620) 672-9922

## Contact information

- **Practice address:** 603 S MAIN ST, PRATT, KS 67124-2630
- **Practice address phone:** (620) 672-9922
- **Practice address fax:** (620) 672-9966
- **Mailing address:** 603 S MAIN ST, PRATT, KS 67124-2630
- **Mailing address phone:** (620) 672-9922
- **Mailing address fax:** (620) 672-9966

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 5971 | KS | Yes |
| 122300000X | Dentist | 60593 | KS | — |

## Other

- **Enumeration date:** 09/11/2008
- **Last updated:** 02/10/2009

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100222640A | — | KS |
| 01 | — | 116863 | BLUE CROSS & BLUE SHEILD | KS |