Provider Demographics
NPI:1104826759
Name:JANDA, MATTHEW CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:CHARLES
Last Name:JANDA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 MELBA RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:CO
Mailing Address - Zip Code:80751-8609
Mailing Address - Country:US
Mailing Address - Phone:970-522-1888
Mailing Address - Fax:970-522-4067
Practice Address - Street 1:801 IRIS DR
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-4740
Practice Address - Country:US
Practice Address - Phone:970-522-4050
Practice Address - Fax:970-522-4067
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02043982Medicaid