Provider Demographics
NPI:1174254544
Name:MAYBERRY, MATTHEW RYAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:RYAN
Other - Middle Name:
Other - Last Name:MAYBERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1100 SOUTH BLVD APT 405
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6520
Mailing Address - Country:US
Mailing Address - Phone:828-301-2875
Mailing Address - Fax:
Practice Address - Street 1:19824 W CATAWBA AVE STE B
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4046
Practice Address - Country:US
Practice Address - Phone:704-987-9087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC102911223G0001X
NC127831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice