Individual
DR. MATTHEW CHARLES MANDEVILLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
4944 SKYVIEW CT, TRAVERSE CITY, MI 49684-7173
(231) 947-4566
Mailing address
4944 SKYVIEW CT, TRAVERSE CITY, MI 49684-7173
(231) 947-4566
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
2901015862
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2974192
—
MI
01
—
D158620
BLUE CROSS BLUE SHIELD MI
MI
Enumeration date
01/04/2007
Last updated
07/08/2007
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