Provider Demographics
NPI:1639111362
Name:GANDOLFO, MATTHEW PETER (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PETER
Last Name:GANDOLFO
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 1:2404 GREATSTONE PT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3274
Mailing Address - Country:US
Mailing Address - Phone:859-224-8111
Mailing Address - Fax:859-224-8211
Practice Address - Street 1:2404 GREATSTONE PT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3274
Practice Address - Country:US
Practice Address - Phone:859-224-8111
Practice Address - Fax:859-224-8211
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice