Healthcare Provider Details

I. General information

NPI: 1811529746
Provider Name (Legal Business Name): MATTHEW EDWARD IMBROGNO DMD, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2020
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 WAKE FOREST RD STE 100
RALEIGH NC
27609-6397
US

IV. Provider business mailing address

367 JUNIPER ISLAND DR
DEFUNIAK SPRINGS FL
32433-3516
US

V. Phone/Fax

Practice location:
  • Phone: 919-876-2464
  • Fax: 919-876-1409
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number11944
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: