Healthcare Provider Details

I. General information

NPI: 1003173386
Provider Name (Legal Business Name): KATIA MATTOS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 12/02/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 SW 160TH AVE
MIRAMAR FL
33027-4212
US

IV. Provider business mailing address

1010 BRICKELL AVE UNIT 4201
MIAMI FL
33131-3790
US

V. Phone/Fax

Practice location:
  • Phone: 954-392-7051
  • Fax:
Mailing address:
  • Phone: 786-208-2820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number30612
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN19592
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: