Healthcare Provider Details

I. General information

NPI: 1407859408
Provider Name (Legal Business Name): MANUEL JOHN MATOS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 W JERSEY ST STE 302
ELIZABETH NJ
07202-1352
US

IV. Provider business mailing address

230 W JERSEY ST STE 302
ELIZABETH NJ
07202-1352
US

V. Phone/Fax

Practice location:
  • Phone: 908-282-6998
  • Fax: 908-282-0306
Mailing address:
  • Phone: 908-282-6998
  • Fax: 908-282-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI02076600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: