Provider Demographics
NPI:1922129261
Name:MATTIACIO, BRIAN L (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:MATTIACIO
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1386 HATHAWAY DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:14425-8973
Mailing Address - Country:US
Mailing Address - Phone:585-742-1050
Mailing Address - Fax:585-742-1011
Practice Address - Street 1:1386 HATHAWAY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-8973
Practice Address - Country:US
Practice Address - Phone:585-742-1050
Practice Address - Fax:585-742-1011
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0515281223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics