Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 30685 | TX |
NPI | 1093053837 |
---|---|
Provider Name | Philip Matson |
First Address | Austin, TX 78759-5279 |
Second Address | Austin, TX 78759-5279 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2013 |
Last Update Date | 21/07/2015 |