MEDICARE: DR. EVAN MATTHYSSE D.D.S.

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	22DI02685300	NJ
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	36043	TX

General Provider Information

NPI Number	:	1205296803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVAN MATTHYSSE D.D.S.

Provider Business Mailing Address
First Line	:	4419 FRONTIER TRL STE 104
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-1567
Country	:	US
Telephone Number	:	917-817-0803
Fax Number	:

Provider Business Practice Location Address
First Line	:	4419 FRONTIER TRL STE 104
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-1567
Country	:	US
Telephone Number	:	917-817-0803
Fax Number	:

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

Provider Enumeration Date	:	02/25/2016
Last Update Date	:	07/23/2024

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