Provider Demographics
NPI:1669762415
Name:WIGGS, MATTHEW JUDSON (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JUDSON
Last Name:WIGGS
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 1:7509 SIX FORKS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5020
Mailing Address - Country:US
Mailing Address - Phone:919-605-0432
Mailing Address - Fax:
Practice Address - Street 1:7509 SIX FORKS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5020
Practice Address - Country:US
Practice Address - Phone:919-605-0432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCIN PROGRESS122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist