Provider Demographics
NPI:1780885616
Name:MATA, JAIME (DDS)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:MATA
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 1:3620 S BRISTOL ST
Mailing Address - Street 2:STE. 306
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7300
Mailing Address - Country:US
Mailing Address - Phone:714-556-5156
Mailing Address - Fax:714-556-5151
Practice Address - Street 1:3620 S BRISTOL ST
Practice Address - Street 2:STE.306
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7300
Practice Address - Country:US
Practice Address - Phone:714-556-5156
Practice Address - Fax:714-556-5151
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306121223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics