Provider Demographics
NPI:1417458696
Name:MATTANA, ZOE REBECCA (DDS)
Entity Type:Individual
Prefix:
First Name:ZOE
Middle Name:REBECCA
Last Name:MATTANA
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 1:4705 44TH ST STE A2
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-6351
Mailing Address - Country:US
Mailing Address - Phone:718-752-9000
Mailing Address - Fax:
Practice Address - Street 1:4705 44TH ST STE A2
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-6351
Practice Address - Country:US
Practice Address - Phone:718-752-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0605441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice