Healthcare Provider Details

I. General information

NPI: 1043586779
Provider Name (Legal Business Name): STUART PEDIATRIC DENTISTRY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SE OCEAN BLVD SUITE A
STUART FL
34994-2448
US

IV. Provider business mailing address

800 SE OCEAN BLVD SUITE A
STUART FL
34994-2448
US

V. Phone/Fax

Practice location:
  • Phone: 772-600-5130
  • Fax: 772-600-5523
Mailing address:
  • Phone: 772-600-5130
  • Fax: 772-600-5523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LUIS A MATOS
Title or Position: PRESIDENT
Credential: DMD
Phone: 772-600-5130