=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356755474
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW BRIGHT D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2014
-----------------------------------------------------
Last Update Date | 01/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 196 EVEREST LN UNIT 1
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-4102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-239-1714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 196 EVEREST LN UNIT 1
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-4102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-239-1714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9463
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DN21734
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------