Healthcare Provider Details

I. General information

NPI: 1437280385
Provider Name (Legal Business Name): MATE DENTAL ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 12/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4075 CR 218 WEST
MIDDLEBURG FL
32068
US

IV. Provider business mailing address

4075 CR 218 WEST
MIDDLEBURG FL
32068
US

V. Phone/Fax

Practice location:
  • Phone: 604-282-9371
  • Fax: 904-282-0905
Mailing address:
  • Phone: 604-282-9371
  • Fax: 904-282-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN13458
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN13093
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDH0013458
License Number StateFL

VIII. Authorized Official

Name: SHANNON M. MATE
Title or Position: OWNER
Credential: DMD
Phone: 904-282-9371