Provider Demographics
NPI:1508000472
Name:MATAISZ, KIMBERLY ANN (RDH)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:MATAISZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:WAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:LANDSTUHL DENTAL ACTIVITY CREDENTIALS OFFICE
Mailing Address - Street 2:CMR 402
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:49637-192-9130
Mailing Address - Fax:49637-192-9117
Practice Address - Street 1:LANDSTUHL DENTAL ACTIVITY CREDENTIALS OFFICE
Practice Address - Street 2:CMR 402
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:US
Practice Address - Phone:49637-192-9130
Practice Address - Fax:49637-192-9117
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2327124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist