Provider Demographics
NPI:1114289246
Name:ANNESE, MATTHEW R (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:R
Last Name:ANNESE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 WILLOW AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2527
Mailing Address - Country:US
Mailing Address - Phone:978-804-3641
Mailing Address - Fax:
Practice Address - Street 1:637 WASHINGTON ST
Practice Address - Street 2:DENTAL DEPARTMENT
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02124-3510
Practice Address - Country:US
Practice Address - Phone:617-822-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856006122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist