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General NPI Number Information
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NPI Number | 1811529746
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Entity Type | Individual
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Provider Name | MATTHEW EDWARD IMBROGNO DMD, MSD
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Gender | Male
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Dates
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Enumeration Date | 02/09/2020
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Last Update Date | 02/04/2025
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Provider Practice Location Address
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Address Line | 4106 WAKE FOREST RD STE 100
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City | RALEIGH
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State | NC
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Zip | 27609-6397
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Country | US
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Telephone | 919-876-2464
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Fax | 919-876-1409
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Provider Business Mailing Address
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Address Line | 367 JUNIPER ISLAND DR
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City | DEFUNIAK SPRINGS
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State | FL
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Zip | 32433-3516
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 11944
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License Number State | NC
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