Provider Demographics
NPI:1033511084
Name:SHANE MATT, DDS PLLC
Entity Type:Organization
Organization Name:SHANE MATT, DDS PLLC
Other - Org Name:AUTHENTIC SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:EDEN
Authorized Official - Last Name:MATT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-330-9403
Mailing Address - Street 1:211 SAN ANTONIO ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-4063
Mailing Address - Country:US
Mailing Address - Phone:512-330-9403
Mailing Address - Fax:512-373-3408
Practice Address - Street 1:211 SAN ANTONIO ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-4063
Practice Address - Country:US
Practice Address - Phone:512-330-9403
Practice Address - Fax:512-373-3408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty