Provider Demographics
NPI:1710049366
Name:JAM, MATT T (DDS)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:T
Last Name:JAM
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 1:81730 HWY 111
Mailing Address - Street 2:SUITE 8
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201
Mailing Address - Country:US
Mailing Address - Phone:760-347-7505
Mailing Address - Fax:760-347-6425
Practice Address - Street 1:81730 HYWAY 111
Practice Address - Street 2:SUITE 8
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201
Practice Address - Country:US
Practice Address - Phone:760-347-7505
Practice Address - Fax:760-347-6425
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA372941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice