Provider Demographics
NPI:1871086405
Name:VIDALES, MATEO (DMD)
Entity type:Individual
Prefix:DR
First Name:MATEO
Middle Name:
Last Name:VIDALES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 WISE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-6830
Mailing Address - Country:US
Mailing Address - Phone:941-408-6601
Mailing Address - Fax:
Practice Address - Street 1:7700 LAKE WILSON RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-9601
Practice Address - Country:US
Practice Address - Phone:863-420-3166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23425122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist