Healthcare Provider Details

I. General information

NPI: 1922256080
Provider Name (Legal Business Name): MRS. TAMMY M MATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 RUBIN DR
RUSHVILLE NY
14544-9681
US

IV. Provider business mailing address

5160 PARRISH STREET EXT
CANANDAIGUA NY
14424-9002
US

V. Phone/Fax

Practice location:
  • Phone: 585-554-6824
  • Fax:
Mailing address:
  • Phone: 585-394-4557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number025383
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: