Healthcare Provider Details

I. General information

NPI: 1407036999
Provider Name (Legal Business Name): MATTHEW THOMAS CARPENTER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MATTHEW THOMAS CARPENTER DMD

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 W 6TH STREET BLDG 440 USA DENTAC
FT STEWART GA
31314
US

IV. Provider business mailing address

351 W 6TH STREET BLDG 440 USA DENTAC
FT STEWART GA
31314
US

V. Phone/Fax

Practice location:
  • Phone: 912-767-6735
  • Fax: 912-767-5425
Mailing address:
  • Phone: 912-767-6735
  • Fax: 912-767-5425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4409
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4409
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4409
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: