MEDICARE: MATTHEW F PROSSER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12142	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D12142	OTHER	TX	BCBS PROVIDER #

General Provider Information

NPI Number	:	1598835258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW F PROSSER D.D.S.

Provider Business Mailing Address
First Line	:	2336 ABERDEEN DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-1943
Country	:	US
Telephone Number	:	903-581-1646
Fax Number	:

Provider Business Practice Location Address
First Line	:	2336 ABERDEEN DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-1943
Country	:	US
Telephone Number	:	903-581-1646
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/08/2007

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