Provider Demographics
NPI:1295732337
Name:MATTERN, THOMAS MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:MATTERN
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 1:4609 E CHANDLER BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0424
Mailing Address - Country:US
Mailing Address - Phone:480-706-4600
Mailing Address - Fax:
Practice Address - Street 1:4609 E CHANDLER BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0424
Practice Address - Country:US
Practice Address - Phone:480-706-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD38921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ094136OtherAHCCCS PROVIDER ID