MEDICARE: MATTHEW DEPIETRO

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	063302	NY

General Provider Information

NPI Number	:	1932856143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW DEPIETRO

Provider Business Mailing Address
First Line	:	6 BROOKHILL DR
Second Line	:
City	:	WEST NYACK
State	:	NY
Zip	:	10994-2102
Country	:	US
Telephone Number	:	516-314-0844
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 SQUADRON BLVD STE 105
Second Line	:
City	:	NEW CITY
State	:	NY
Zip	:	10956-5268
Country	:	US
Telephone Number	:	845-634-8866
Fax Number	:

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

Provider Enumeration Date	:	03/08/2022
Last Update Date	:	09/03/2024

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