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General NPI Number Information
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NPI Number | 1144613431
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Entity Type | Individual
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Provider Name | JESSICA MATTERN D.D.S
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Gender | Female
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Dates
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Enumeration Date | 03/10/2015
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Last Update Date | 07/25/2016
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Provider Practice Location Address
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Address Line | 1516 JARRET PL
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City | BRONX
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State | NY
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Zip | 10461-2607
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Country | US
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Telephone | 718-405-8194
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Fax |
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Provider Business Mailing Address
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Address Line | 4846 W FOSTER AVE
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City | CHICAGO
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State | IL
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Zip | 60630-1640
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Country | US
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Telephone | 480-794-0302
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 019.030577
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License Number State | IL
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