Provider Demographics
NPI:1306879200
Name:MATTESON, ROBERT DARRELL (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DARRELL
Last Name:MATTESON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 SWEETWATER TRL
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-0916
Mailing Address - Country:US
Mailing Address - Phone:407-679-9402
Mailing Address - Fax:
Practice Address - Street 1:1340 TUSKAWILLA RD
Practice Address - Street 2:108
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-5030
Practice Address - Country:US
Practice Address - Phone:407-695-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN85711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice