Healthcare Provider Details

I. General information

NPI: 1790196822
Provider Name (Legal Business Name): JEFFREY DANIEL MONACO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 MATTHEWS TOWNSHIP PKWY #201
MATTHEWS NC
28105
US

IV. Provider business mailing address

1340 MATTHEWS TOWNSHIP PKWY #201
MATTHEWS NC
28105
US

V. Phone/Fax

Practice location:
  • Phone: 704-847-4717
  • Fax: 585-273-3485
Mailing address:
  • Phone: 585-276-3145
  • Fax: 585-273-3485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10483
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: