Provider Demographics
NPI:1205109436
Name:BAGNALL, MATTHEW LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LEE
Last Name:BAGNALL
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 1:16 HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3002
Mailing Address - Country:US
Mailing Address - Phone:978-475-3997
Mailing Address - Fax:
Practice Address - Street 1:16 HAVERHILL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3002
Practice Address - Country:US
Practice Address - Phone:978-475-3997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-19
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18565711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice