Healthcare Provider Details

I. General information

NPI: 1255401840
Provider Name (Legal Business Name): JORGE A MATOS D.D.S., C.A.G.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 WESTFIELD AVE SUITE 206
ELIZABETH NJ
07208-1658
US

IV. Provider business mailing address

520 WESTFIELD AVE SUITE 206
ELIZABETH NJ
07208-1658
US

V. Phone/Fax

Practice location:
  • Phone: 908-354-4428
  • Fax:
Mailing address:
  • Phone: 908-354-4428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDI20670
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: