MEDICARE: DR. MATTHEW R. WOLPERT DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	8289908-9922	UT

General Provider Information

NPI Number	:	1093087629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW R. WOLPERT DMD

Provider Business Mailing Address
First Line	:	3860 JACKSON AVE STE 6
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84403-1979
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3860 JACKSON AVE STE 6
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84403-1979
Country	:	US
Telephone Number	:	801-627-0420
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2012
Last Update Date	:	04/19/2013

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