Healthcare Provider Details

I. General information

NPI: 1659635175
Provider Name (Legal Business Name): MATTHEW FRANK LALLI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 FLAGLER AVE
KEY WEST FL
33040
US

IV. Provider business mailing address

3110 GRAND AVE COURTLAND SATORI
PINELLAS PARK FL
33782
US

V. Phone/Fax

Practice location:
  • Phone: 305-294-6696
  • Fax:
Mailing address:
  • Phone: 914-552-2281
  • Fax: 914-968-2474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13173
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number50-058609
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number058609
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN27595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: