Provider Demographics
NPI:1003964339
Name:MATYTSIN, VLADA (DDS)
Entity Type:Individual
Prefix:DR
First Name:VLADA
Middle Name:
Last Name:MATYTSIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4840 SWEETWATER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-3403
Mailing Address - Country:US
Mailing Address - Phone:832-939-9999
Mailing Address - Fax:832-939-9997
Practice Address - Street 1:4840 SWEETWATER BLVD STE A
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479
Practice Address - Country:US
Practice Address - Phone:832-939-9999
Practice Address - Fax:832-939-9997
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30466122300000X
NY0513371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3403552-05Medicaid
TX3403552-04Medicaid
TX3403552-06Medicaid
NY02608157Medicaid