Provider Demographics
NPI:1912121849
Name:MATT, SHANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:MATT
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 1:211 SAN ANTONIO STREET
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701
Mailing Address - Country:US
Mailing Address - Phone:512-330-9403
Mailing Address - Fax:512-373-3408
Practice Address - Street 1:211 SAN ANTONIO ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701
Practice Address - Country:US
Practice Address - Phone:512-330-9403
Practice Address - Fax:512-373-3408
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDS-198581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice