=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043586779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STUART PEDIATRIC DENTISTRY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2012
-----------------------------------------------------
Last Update Date | 03/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 SE OCEAN BLVD SUITE A
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994-2448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-600-5130
-----------------------------------------------------
Fax | 772-600-5523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 SE OCEAN BLVD SUITE A
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994-2448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-600-5130
-----------------------------------------------------
Fax | 772-600-5523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LUIS A MATOS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 772-600-5130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1223P0106X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 126900000X
-----------------------------------------------------
Taxonomy Name | Dental Laboratory Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------