MEDICARE: DR. MATTHEW C POORE DDS

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DS038197	PA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	051226	NY
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	9514	SC

General Provider Information

NPI Number	:	1750592770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW C POORE DDS

Provider Business Mailing Address
First Line	:	225 KILGORE CIR
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-4835
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	668 FAIRVIEW RD STE B
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29680-6708
Country	:	US
Telephone Number	:	864-881-7098
Fax Number	:

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

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	12/24/2020

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