Provider Demographics
NPI:1033473996
Name:MATUS, SAMANTHA C (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:C
Last Name:MATUS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2244
Mailing Address - Country:US
Mailing Address - Phone:860-828-1475
Mailing Address - Fax:
Practice Address - Street 1:1067 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-2244
Practice Address - Country:US
Practice Address - Phone:860-828-1475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT111521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004011136Medicaid