Provider Demographics
NPI:1265000319
Name:MATA ALVAREZ, LISETT (DDS)
Entity Type:Individual
Prefix:
First Name:LISETT
Middle Name:
Last Name:MATA ALVAREZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4208 SW SANTA BARBARA PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-8434
Mailing Address - Country:US
Mailing Address - Phone:786-916-4453
Mailing Address - Fax:
Practice Address - Street 1:18070 S TAMIAMI TRL # 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4602
Practice Address - Country:US
Practice Address - Phone:239-236-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28432122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist