=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083950703
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANESSA IVELISSE MATOS DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2012
-----------------------------------------------------
Last Update Date | 03/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 MAIN ST
-----------------------------------------------------
City | LANDISVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17538-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-898-7221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2515 PAMPAS DR
-----------------------------------------------------
City | YORK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17404-6430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-764-8083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS029521L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------