Provider Demographics
NPI:1043586779
Name:STUART PEDIATRIC DENTISTRY, P.A.
Entity type:Organization
Organization Name:STUART PEDIATRIC DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:772-600-5130
Mailing Address - Street 1:800 SE OCEAN BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2448
Mailing Address - Country:US
Mailing Address - Phone:772-600-5130
Mailing Address - Fax:772-600-5523
Practice Address - Street 1:800 SE OCEAN BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2448
Practice Address - Country:US
Practice Address - Phone:772-600-5130
Practice Address - Fax:772-600-5523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
No126900000XDental ProvidersDental Laboratory TechnicianGroup - Multi-Specialty