Provider Demographics
NPI:1376799445
Name:MATA, XAVIER (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:XAVIER
Middle Name:
Last Name:MATA
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8608 S 30TH WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-8249
Mailing Address - Country:US
Mailing Address - Phone:480-268-1569
Mailing Address - Fax:
Practice Address - Street 1:8608 S 30TH WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-8249
Practice Address - Country:US
Practice Address - Phone:480-268-1569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA600141223P0300X
MD142451223P0300X
AZ80751223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics