MEDICARE: DR. ROBERT J MATLACH 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	1223G0001X	General Practice Dentistry	047570	NY

General Provider Information

NPI Number	:	1952521114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT J MATLACH DDS

Provider Business Mailing Address
First Line	:	158 EAST MAIN ST
Second Line	:	SUITE #5
City	:	HUNTINGTON
State	:	NY
Zip	:	11743-2968
Country	:	US
Telephone Number	:	631-421-3388
Fax Number	:	631-421-3414

Provider Business Practice Location Address
First Line	:	158 EAST MAIN ST
Second Line	:	SUITE #5
City	:	HUNTINGTON
State	:	NY
Zip	:	11743-2968
Country	:	US
Telephone Number	:	631-421-3388
Fax Number	:	631-421-3414

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

Provider Enumeration Date	:	04/27/2007
Last Update Date	:	07/08/2007

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