=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124846910
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FADI JAMAL MATTI DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2024
-----------------------------------------------------
Last Update Date | 08/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1109 W BROAD ST
-----------------------------------------------------
City | CHESANING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48616-1088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-845-7242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1109 W BROAD ST
-----------------------------------------------------
City | CHESANING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48616-1088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-845-7242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901602292
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------