Provider Demographics
NPI:1780768945
Name:SMITH, MATTHEW (MD, DDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 PANORAMA TRL
Mailing Address - Street 2:BLDG 2, SUITE 230
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2404
Mailing Address - Country:US
Mailing Address - Phone:585-264-1970
Mailing Address - Fax:
Practice Address - Street 1:625 PANORAMA TRL
Practice Address - Street 2:BLDG 2, SUITE 230
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2404
Practice Address - Country:US
Practice Address - Phone:585-264-1970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045285-11223S0112X
NY213109204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH52584Medicare UPIN