Provider Demographics
NPI:1538348321
Name:BRENNAN, MATTHEW M (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:M
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 WARWICK AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-5026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1434 WARWICK AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-5026
Practice Address - Country:US
Practice Address - Phone:401-463-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN25871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
139-741OtherUNITED CONCORDIA
41-00012OtherUNITED HEALTHCARE
8037-4OtherBLUE CROSS
RIWB01101Medicaid
RG0069OtherBLUE CROSS MASS