Healthcare Provider Details

I. General information

NPI: 1669088852
Provider Name (Legal Business Name): MATTHEW DEJONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KLEBER DENTAL CLINIC BLDG 3287
APO AE
09227
US

IV. Provider business mailing address

KLEBER DENTAL CLINIC KLEBER KASERNE, MANNHEIMER STR. 3287
KAISERSLAUTERN RHEINLAND PFALZ
67657
DE

V. Phone/Fax

Practice location:
  • Phone: 314-590-2620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD11339
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: