MEDICARE: DR. MATTHEW ADAM DEFELICE D.D.S.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	5196	AZ

General Provider Information

NPI Number	:	1013914696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW ADAM DEFELICE D.D.S.

Provider Business Mailing Address
First Line	:	5315 E HIGH ST
Second Line	:	SUITE 119
City	:	PHOENIX
State	:	AZ
Zip	:	85054-5438
Country	:	US
Telephone Number	:	480-563-3960
Fax Number	:

Provider Business Practice Location Address
First Line	:	5315 E HIGH ST
Second Line	:	SUITE 119
City	:	PHOENIX
State	:	AZ
Zip	:	85054-5438
Country	:	US
Telephone Number	:	480-563-3960
Fax Number	:	480-563-3965

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

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	02/27/2017

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