Provider Demographics
NPI:1558375907
Name:PALMER, MATTHEW TAIT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TAIT
Last Name:PALMER
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 1:2616 CASCADE FALLS DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738-5300
Mailing Address - Country:US
Mailing Address - Phone:512-402-9575
Mailing Address - Fax:
Practice Address - Street 1:1010 MO PAC CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-6865
Practice Address - Country:US
Practice Address - Phone:512-327-7930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice