Provider Demographics
NPI:1053685008
Name:MATIS, JEREMY ISAK (DDS)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:ISAK
Last Name:MATIS
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 1:92D MEDICAL GROUP
Mailing Address - Street 2:701 HOSPITAL LOOP, SUITE 350
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011
Mailing Address - Country:US
Mailing Address - Phone:509-247-4770
Mailing Address - Fax:
Practice Address - Street 1:92D MEDICAL GROUP
Practice Address - Street 2:701 HOSPITAL LOOP, SUITE 350
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011
Practice Address - Country:US
Practice Address - Phone:095-247-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN12011813A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program