=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952084659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATEO CASTRO DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2023
-----------------------------------------------------
Last Update Date | 08/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 603 S STATE ROAD 7 STE A
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33023-6723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-802-3574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 W HALLANDALE BEACH BLVD
-----------------------------------------------------
City | HALLANDALE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009-5412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-510-9997
-----------------------------------------------------
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 | DN28416
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------