Provider Demographics
NPI:1891910378
Name:MATTILA, JEFFREY RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:RAY
Last Name:MATTILA
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 1:200 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2828
Mailing Address - Country:US
Mailing Address - Phone:505-287-2000
Mailing Address - Fax:
Practice Address - Street 1:200 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2828
Practice Address - Country:US
Practice Address - Phone:505-287-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1754122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist