Provider Demographics
NPI:1053331892
Name:RECORD, MATTHEW TOM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TOM
Last Name:RECORD
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 1:212 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-5013
Mailing Address - Country:US
Mailing Address - Phone:940-665-4761
Mailing Address - Fax:940-665-0199
Practice Address - Street 1:212 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-5013
Practice Address - Country:US
Practice Address - Phone:940-665-4761
Practice Address - Fax:940-665-0199
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX197281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice