Provider Demographics
NPI:1689726150
Name:MASTROMATTEO, JOSEPH ANTHONY (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:MASTROMATTEO
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 1:312 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-2794
Mailing Address - Country:US
Mailing Address - Phone:248-693-1331
Mailing Address - Fax:248-693-1385
Practice Address - Street 1:312 SOUTH BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-2794
Practice Address - Country:US
Practice Address - Phone:248-693-1331
Practice Address - Fax:248-693-1385
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI82591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice