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NPI Code Detail

MEDICARE: DR. MATTHEW PETER GANDOLFO DMD

MEDICARE: DR. MATTHEW PETER GANDOLFO 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
11223G0001XGeneral Practice Dentistry3960KY

General Provider Information

NPI Number : 1639111362
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MATTHEW PETER GANDOLFO DMD
Provider Business Mailing Address
First Line : 2404 GREATSTONE PT
Second Line :
City : LEXINGTON
State : KY
Zip : 40504-3274
Country : US
Telephone Number : 859-224-8111
Fax Number : 859-224-8211
Provider Business Practice Location Address
First Line : 2404 GREATSTONE PT
Second Line :
City : LEXINGTON
State : KY
Zip : 40504-3274
Country : US
Telephone Number : 859-224-8111
Fax Number : 859-224-8211
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2006
Last Update Date : 07/08/2007

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