Provider Demographics
NPI:1699325795
Name:MATTOS, JOHN CHRISTOPHER (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:MATTOS
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:PO BOX 6809
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-8934
Mailing Address - Country:US
Mailing Address - Phone:808-937-4801
Mailing Address - Fax:
Practice Address - Street 1:1452 HUDSON ST STE 200
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3727
Practice Address - Country:US
Practice Address - Phone:360-425-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60987782122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist