Healthcare Provider Details

I. General information

NPI: 1518698927
Provider Name (Legal Business Name): MELISSA ANNE MATICK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4447 CAMINO REAL WAY
FORT MYERS FL
33966-1019
US

IV. Provider business mailing address

4447 CAMINO REAL WAY
FORT MYERS FL
33966-1019
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-7400
  • Fax:
Mailing address:
  • Phone: 239-936-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN27136
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: