Provider Demographics
NPI:1043661614
Name:WETTACH, MATTHEW BENJAMIN (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BENJAMIN
Last Name:WETTACH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2436 IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:IA
Mailing Address - Zip Code:52641-8200
Mailing Address - Country:US
Mailing Address - Phone:319-931-4626
Mailing Address - Fax:
Practice Address - Street 1:501 S WHITE ST STE 28
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:IA
Practice Address - Zip Code:52641-2600
Practice Address - Country:US
Practice Address - Phone:319-385-6750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-093091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice