Organization
MAIN STREET DENTAL, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHN D. MATHES DDS (OWNER)
(620) 672-9922
Entity
Organization
Contact information
Practice address
603 S MAIN ST, PRATT, KS 67124-2630
(620) 672-9922
(620) 672-9966
Mailing address
603 S MAIN ST, PRATT, KS 67124-2630
(620) 672-9922
(620) 672-9966
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
5971
KS
122300000X
Dentist
60593
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100222640A
—
KS
01
—
116863
BLUE CROSS & BLUE SHEILD
KS
Enumeration date
09/11/2008
Last updated
02/10/2009
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