Provider Demographics
NPI:1952543381
Name:STAAT, MATTHEW ADAM (DD,S,)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ADAM
Last Name:STAAT
Suffix:
Gender:M
Credentials:DD,S,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 COAHUILA LOOP
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-6635
Mailing Address - Country:US
Mailing Address - Phone:909-648-6198
Mailing Address - Fax:
Practice Address - Street 1:1400 GUADALUPE ST
Practice Address - Street 2:STE A
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-5315
Practice Address - Country:US
Practice Address - Phone:909-648-6198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-31
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57405122300000X
TX26338122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist