=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447341656
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW GERARD NIEMIERA D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 AMBOY AVE SUITE 105
-----------------------------------------------------
City | PERTH AMBOY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08861-2577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-442-4455
-----------------------------------------------------
Fax | 732-442-2248
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 613 AMBOY AVE SUITE 105
-----------------------------------------------------
City | PERTH AMBOY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08861-2577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-442-4455
-----------------------------------------------------
Fax | 732-442-2248
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DI01145800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------