Provider Demographics
NPI:1588005490
Name:FOURNIER, MATTHEW BRUCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BRUCE
Last Name:FOURNIER
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 1:77 SOUTH SHORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-5822
Mailing Address - Country:US
Mailing Address - Phone:850-262-9488
Mailing Address - Fax:
Practice Address - Street 1:77 SOUTH SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-5822
Practice Address - Country:US
Practice Address - Phone:850-262-9488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN204951223G0001X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program