Healthcare Provider Details

I. General information

NPI: 1366070351
Provider Name (Legal Business Name): JONNATHAN MATUTE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 US HIGHWAY 46
ROCKAWAY NJ
07866-3826
US

IV. Provider business mailing address

345 VINE ST
ELIZABETH NJ
07202-1817
US

V. Phone/Fax

Practice location:
  • Phone: 973-627-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02808200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: