Provider Demographics
NPI:1598835258
Name:PROSSER, MATTHEW F (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:F
Last Name:PROSSER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:M
Other - Middle Name:F
Other - Last Name:PROSSER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2336 ABERDEEN DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1943
Mailing Address - Country:US
Mailing Address - Phone:903-581-1646
Mailing Address - Fax:
Practice Address - Street 1:2336 ABERDEEN DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1943
Practice Address - Country:US
Practice Address - Phone:903-581-1646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD12142OtherBCBS PROVIDER #