MEDICARE: DR. VANESSA IVELISSE MATOS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DS029521L	PA

General Provider Information

NPI Number	:	1083950703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VANESSA IVELISSE MATOS DDS

Provider Business Mailing Address
First Line	:	2515 PAMPAS DR
Second Line	:
City	:	YORK
State	:	PA
Zip	:	17404-6430
Country	:	US
Telephone Number	:	717-764-8083
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 MAIN ST
Second Line	:
City	:	LANDISVILLE
State	:	PA
Zip	:	17538-1812
Country	:	US
Telephone Number	:	717-898-7221
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2012
Last Update Date	:	03/25/2014

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