Basic Information
Provider Information | |||||||||
NPI: | 1518957778 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AUSMUS | ||||||||
FirstName: | MATHEW | ||||||||
MiddleName: | S. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 579 | ||||||||
Address2: |   | ||||||||
City: | ROLLA | ||||||||
State: | MO | ||||||||
PostalCode: | 65402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5734583425 | ||||||||
FaxNumber: | 5734262282 | ||||||||
Practice Location | |||||||||
Address1: | 1050 W 10TH ST | ||||||||
Address2: |   | ||||||||
City: | ROLLA | ||||||||
State: | MO | ||||||||
PostalCode: | 65401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5734262233 | ||||||||
FaxNumber: | 5733643993 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/27/2005 | ||||||||
LastUpdateDate: | 08/22/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 014015 | MO | Y |   | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
ID | Type | State | Issuer | Description | 408413003 | 05 | MO |   | MEDICAID |