Provider Demographics
NPI:1053978064
Name:MATTHEW A. BAGNULO, DDS, PS
Entity type:Organization
Organization Name:MATTHEW A. BAGNULO, DDS, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:BAGNULO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-821-9000
Mailing Address - Street 1:11830 NE 128TH ST., #202
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034
Mailing Address - Country:US
Mailing Address - Phone:425-821-9000
Mailing Address - Fax:425-814-2908
Practice Address - Street 1:11830 NE 128TH ST., #202
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034
Practice Address - Country:US
Practice Address - Phone:425-821-9000
Practice Address - Fax:425-814-2908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty