Provider Demographics
NPI:1720369853
Name:MILLBURY FAMILY DENTISTRY, P.C.
Entity Type:Organization
Organization Name:MILLBURY FAMILY DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-865-2622
Mailing Address - Street 1:116 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01527-2021
Mailing Address - Country:US
Mailing Address - Phone:508-865-2622
Mailing Address - Fax:508-865-1676
Practice Address - Street 1:116 MAIN ST.
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:MA
Practice Address - Zip Code:01527-2021
Practice Address - Country:US
Practice Address - Phone:508-865-2622
Practice Address - Fax:508-865-1676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN15100122300000X
MADN1855061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110010202AMedicaid