Provider Demographics
NPI:1013229541
Name:MATAIA, LIBERTY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:LIBERTY
Middle Name:J
Last Name:MATAIA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LIBERTY
Other - Middle Name:
Other - Last Name:FRANKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:601 N KEYS RD
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-1172
Mailing Address - Country:US
Mailing Address - Phone:509-865-2395
Mailing Address - Fax:
Practice Address - Street 1:602 E NOB HILL BLVD
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-3534
Practice Address - Country:US
Practice Address - Phone:509-248-3334
Practice Address - Fax:509-453-6144
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601560431223X0400X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1013229541Medicaid