Provider Demographics
NPI:1710406236
Name:WITELUS, MATEUSZ TOMASZ (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATEUSZ
Middle Name:TOMASZ
Last Name:WITELUS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 SUFFOLK CIR
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-1638
Mailing Address - Country:US
Mailing Address - Phone:941-468-7186
Mailing Address - Fax:
Practice Address - Street 1:870 N US HIGHWAY 27 STE A
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-3108
Practice Address - Country:US
Practice Address - Phone:352-282-4785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist