Provider Demographics
NPI:1114396629
Name:MATTHEW MASTROROCCO DMD, PA
Entity Type:Organization
Organization Name:MATTHEW MASTROROCCO DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MASTROROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-682-4601
Mailing Address - Street 1:4101 MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:HILTON HEAD
Mailing Address - State:SC
Mailing Address - Zip Code:29926-4608
Mailing Address - Country:US
Mailing Address - Phone:843-682-4601
Mailing Address - Fax:843-682-4602
Practice Address - Street 1:4101 MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926-4608
Practice Address - Country:US
Practice Address - Phone:843-682-4601
Practice Address - Fax:843-682-4602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3732261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental