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General NPI Number Information
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NPI Number | 1952824989
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Entity Type | Individual
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Provider Name | DIANA MATATOVA DMD
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Gender | Female
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Dates
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Enumeration Date | 07/21/2017
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Last Update Date | 03/07/2018
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Provider Practice Location Address
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Address Line | 5311 E BROADWAY BLVD
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City | TUCSON
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State | AZ
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Zip | 85711-3710
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Country | US
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Telephone | 520-468-6836
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Fax |
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Provider Business Mailing Address
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Address Line | 1844 W BUTLER DR
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City | PHOENIX
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State | AZ
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Zip | 85021-5264
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Country | US
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Telephone |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 33328
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License Number State | TX
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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 | D009933
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License Number State | AZ
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