Provider Demographics
NPI:1912434549
Name:TENAGLIA, MATTHEW S (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:TENAGLIA
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 1:1601 SPRING GARDEN ST APT 305
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3943
Mailing Address - Country:US
Mailing Address - Phone:484-620-1355
Mailing Address - Fax:
Practice Address - Street 1:909 WALNUT ST RM 300
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-503-7118
Practice Address - Fax:215-923-9189
Is Sole Proprietor?:No
Enumeration Date:2017-05-14
Last Update Date:2017-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program