Provider Demographics
NPI:1932399599
Name:STORM, MATTHEW TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TODD
Last Name:STORM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10740 COURTHOUSE RD STE C
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-1601
Mailing Address - Country:US
Mailing Address - Phone:540-898-8555
Mailing Address - Fax:540-891-2763
Practice Address - Street 1:10740 COURTHOUSE RD STE C
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-1601
Practice Address - Country:US
Practice Address - Phone:540-898-8555
Practice Address - Fax:540-891-2763
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010066691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice