Basic Information
| Provider Information | |||||||||
| NPI: | 1013350495 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTE | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 640 | ||||||||
| Address2: | |||||||||
| City: | ISLETA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870220640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059254031 | ||||||||
| FaxNumber: | 5059254030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SAGEBRUSH ST SW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871053942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059254031 | ||||||||
| FaxNumber: | 5059254030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2013 | ||||||||
| LastUpdateDate: | 12/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DD4201 | NM | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | DD4201 | 01 | NM | LICENSE | OTHER |