=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538505615
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW NICHOLSON DAMIN D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2013
-----------------------------------------------------
Last Update Date | 11/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1830 DESTINY LN SUITE 119
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-1087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-393-9925
-----------------------------------------------------
Fax | 270-393-9928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1830 DESTINY LN SUITE 119
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-1087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-393-9925
-----------------------------------------------------
Fax | 270-393-9928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 9573
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------