MEDICARE: DR. BRIAN L MATTIACIO D.D.S., M.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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	051528	NY

General Provider Information

NPI Number	:	1922129261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN L MATTIACIO D.D.S., M.S.

Provider Business Mailing Address
First Line	:	1386 HATHAWAY DR
Second Line	:
City	:	FARMINGTON
State	:	NY
Zip	:	14425-8973
Country	:	US
Telephone Number	:	585-742-1050
Fax Number	:	585-742-1011

Provider Business Practice Location Address
First Line	:	1386 HATHAWAY DR
Second Line	:
City	:	FARMINGTON
State	:	NY
Zip	:	14425-8973
Country	:	US
Telephone Number	:	585-742-1050
Fax Number	:	585-742-1011

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

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	07/08/2007

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