Provider Demographics
NPI:1922256080
Name:MATSON, TAMMY M
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:M
Last Name:MATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5160 PARRISH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-9002
Mailing Address - Country:US
Mailing Address - Phone:585-394-4557
Mailing Address - Fax:
Practice Address - Street 1:2 RUBIN DR
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:NY
Practice Address - Zip Code:14544-9681
Practice Address - Country:US
Practice Address - Phone:585-554-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025383124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00618199Medicaid