Healthcare Provider Details

I. General information

NPI: 1508153099
Provider Name (Legal Business Name): PETRO MATSYSHYN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MAIN ST
HARTFORD CT
06106-1860
US

IV. Provider business mailing address

119 TOWNE ST APT. 464
STAMFORD CT
06902-5952
US

V. Phone/Fax

Practice location:
  • Phone: 860-899-2804
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02484400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number010721
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: