Provider Demographics
NPI:1598821167
Name:MATRULLO, JOSEPH P (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:P
Last Name:MATRULLO
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 1:1280 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-3033
Mailing Address - Country:US
Mailing Address - Phone:401-943-0644
Mailing Address - Fax:401-943-3276
Practice Address - Street 1:1280 PARK AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-3033
Practice Address - Country:US
Practice Address - Phone:401-943-0644
Practice Address - Fax:401-943-3276
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI28391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice