Provider Demographics
NPI:1679681795
Name:CARPENTER, MATTHEW FORREST (DDS,PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:FORREST
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:DDS,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 N LAKE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4936
Mailing Address - Country:US
Mailing Address - Phone:512-255-3618
Mailing Address - Fax:512-255-1419
Practice Address - Street 1:323 N LAKE CREEK DR
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4936
Practice Address - Country:US
Practice Address - Phone:512-255-3618
Practice Address - Fax:512-255-1419
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1456499OtherUNITED CONCORDIA INS.