Healthcare Provider Details

I. General information

NPI: 1407112600
Provider Name (Legal Business Name): ADAM C. MATTHIAS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 FREDERICK AVE SUITE A
ST JOSEPH MO
64506-2959
US

IV. Provider business mailing address

3109 FREDERICK AVE SUITE A
ST JOSEPH MO
64506-2959
US

V. Phone/Fax

Practice location:
  • Phone: 816-364-4774
  • Fax: 816-364-4373
Mailing address:
  • Phone: 816-364-4774
  • Fax: 816-364-4373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2016007792
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: