=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689824229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATTHEW W. DEVANEY, D.D.S. & ASSOCIATES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2008
-----------------------------------------------------
Last Update Date | 03/31/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6161 LAKE BRANDT RD UNIT A
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27455-8415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-643-1440
-----------------------------------------------------
Fax | 336-643-1065
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6161 LAKE BRANDT RD UNIT A
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27455-8415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-643-1440
-----------------------------------------------------
Fax | 336-643-1065
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MATTHEW W DEVANEY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 336-643-1440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | NC6974
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | NC8237
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------