Provider Demographics
NPI:1003948563
Name:MATTISON, CHARLES ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALBERT
Last Name:MATTISON
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 1:933 CENTINELA AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-1501
Mailing Address - Country:US
Mailing Address - Phone:310-677-4085
Mailing Address - Fax:310-677-1357
Practice Address - Street 1:933 CENTINELA AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-1501
Practice Address - Country:US
Practice Address - Phone:310-677-4085
Practice Address - Fax:310-677-1357
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21034122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB21034 01OtherDENTICAL