Healthcare Provider Details

I. General information

NPI: 1356317200
Provider Name (Legal Business Name): MATTHEW GAWORSKI D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6140 TUTT BLVD
COLORADO SPRINGS CO
80922-3575
US

IV. Provider business mailing address

6140 TUTT BLVD
COLORADO SPRINGS CO
80922-3578
US

V. Phone/Fax

Practice location:
  • Phone: 719-596-2477
  • Fax: 719-597-9902
Mailing address:
  • Phone: 719-596-2477
  • Fax: 719-597-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7525
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: