Healthcare Provider Details

I. General information

NPI: 1780694836
Provider Name (Legal Business Name): MATTHEW W PANAGIOTU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 PLEASANT ST
WORCESTER MA
01609-3208
US

IV. Provider business mailing address

144 PLEASANT ST
WORCESTER MA
01609-3208
US

V. Phone/Fax

Practice location:
  • Phone: 508-754-9825
  • Fax: 508-754-9831
Mailing address:
  • Phone: 508-754-9825
  • Fax: 508-754-9831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9917
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0228559
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: