Basic Information
| Provider Information | |||||||||
| NPI: | 1295916419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGNEW | ||||||||
| FirstName: | MATT | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 W. BELTLINE HWY. | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537134226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084435500 | ||||||||
| FaxNumber: | 6084411981 | ||||||||
| Practice Location | |||||||||
| Address1: | 1270 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SUN PRAIRIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535901930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084435482 | ||||||||
| FaxNumber: | 6088379134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2007 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | 6179-15 | WI | Y | Dental Providers | Dentist | Dental Public Health |
ID Information
| ID | Type | State | Issuer | Description | 33815700 | 05 | WI | MEDICAID |