Provider Demographics
NPI:1811529746
Name:IMBROGNO, MATTHEW EDWARD (DMD, MSD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EDWARD
Last Name:IMBROGNO
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 JUNIPER ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-3516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4106 WAKE FOREST RD STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6397
Practice Address - Country:US
Practice Address - Phone:919-876-2464
Practice Address - Fax:919-876-1409
Is Sole Proprietor?:No
Enumeration Date:2020-02-09
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC119441223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics