MEDICARE: DR. THOMAS MICHAEL MATTERN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D3892	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	094136	OTHER	AZ	AHCCCS PROVIDER ID

General Provider Information

NPI Number	:	1295732337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS MICHAEL MATTERN D.D.S.

Provider Business Mailing Address
First Line	:	4609 E CHANDLER BLVD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-0424
Country	:	US
Telephone Number	:	480-706-4600
Fax Number	:

Provider Business Practice Location Address
First Line	:	4609 E CHANDLER BLVD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-0424
Country	:	US
Telephone Number	:	480-706-4600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	05/21/2015

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