Provider Demographics
NPI:1710984695
Name:MATTHEWS, JOSEPH D JR
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:D
Last Name:MATTHEWS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 W PARK PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3566
Mailing Address - Country:US
Mailing Address - Phone:470-986-1004
Mailing Address - Fax:
Practice Address - Street 1:2415 W PARK PLACE BLVD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3566
Practice Address - Country:US
Practice Address - Phone:470-986-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0089971223X2210X
NMDD16731223G0001X
GADN1230161223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X2210XDental ProvidersDentistOrofacial Pain
No1223G0001XDental ProvidersDentistGeneral Practice