Healthcare Provider Details

I. General information

NPI: 1215948385
Provider Name (Legal Business Name): MICHAEL S MATHEWS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 THONOTOSASSA RD STE A
PLANT CITY FL
33563-2972
US

IV. Provider business mailing address

2005 THONOTOSASSA RD STE A
PLANT CITY FL
33563-2972
US

V. Phone/Fax

Practice location:
  • Phone: 813-754-3794
  • Fax: 813-754-1677
Mailing address:
  • Phone: 813-754-3794
  • Fax: 813-754-1677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN14621
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: