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General NPI Number Information
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NPI Number | 1699256693
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Entity Type | Individual
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Provider Name | MARCELO BARBOSA DE ACCIOLY MATTOS DMD
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Gender | Male
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Dates
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Enumeration Date | 08/27/2018
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Last Update Date | 02/14/2020
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Provider Practice Location Address
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Address Line | 800 ROSE ST
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City | LEXINGTON
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State | KY
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Zip | 40536-4325
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Country | US
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Telephone | 859-323-7595
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Fax |
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Provider Business Mailing Address
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Address Line | 800 ROSE ST # D104
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City | LEXINGTON
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State | KY
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Zip | 40536-7001
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Country | US
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Telephone | 859-323-7595
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 125
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 10400
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License Number State | KY
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