Provider Demographics
NPI:1437280385
Name:MATE DENTAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:MATE DENTAL ASSOCIATES, INC
Other - Org Name:SHANNON M. MATE, DMD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-282-9371
Mailing Address - Street 1:4075 CR 218 WEST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068
Mailing Address - Country:US
Mailing Address - Phone:604-282-9371
Mailing Address - Fax:904-282-0905
Practice Address - Street 1:4075 CR 218 WEST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068
Practice Address - Country:US
Practice Address - Phone:604-282-9371
Practice Address - Fax:904-282-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13458122300000X
FLDN13093122300000X
FLDH00134581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty