Provider Demographics
NPI:1093237497
Name:ANDENMATTEN, THALITA
Entity Type:Individual
Prefix:
First Name:THALITA
Middle Name:
Last Name:ANDENMATTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 1/2 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01821-1431
Mailing Address - Country:US
Mailing Address - Phone:508-857-7508
Mailing Address - Fax:
Practice Address - Street 1:203 TURNPIKE ST
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-5042
Practice Address - Country:US
Practice Address - Phone:508-857-7508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL132821223D0001X
MADL136721223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1093237497Medicaid