Provider Demographics
NPI:1407859408
Name:MATOS, MANUEL JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:JOHN
Last Name:MATOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 W JERSEY ST
Mailing Address - Street 2:STE 302
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-1352
Mailing Address - Country:US
Mailing Address - Phone:908-282-6998
Mailing Address - Fax:908-282-0306
Practice Address - Street 1:230 W JERSEY ST
Practice Address - Street 2:STE 302
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-1352
Practice Address - Country:US
Practice Address - Phone:908-282-6998
Practice Address - Fax:908-282-0306
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI020766001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8265607Medicaid
NJ077920Medicare ID - Type Unspecified
NJU99410Medicare UPIN