Provider Demographics
NPI:1366070351
Name:MATUTE, JONNATHAN (DMD)
Entity type:Individual
Prefix:
First Name:JONNATHAN
Middle Name:
Last Name:MATUTE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 VINE ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-1817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:272 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-3826
Practice Address - Country:US
Practice Address - Phone:973-627-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI028082001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program