Provider Demographics
NPI:1073008470
Name:BOUFFORD, MATTHEW RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RICHARD
Last Name:BOUFFORD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 TURQUOISE ST APT D
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-1211
Mailing Address - Country:US
Mailing Address - Phone:562-544-2910
Mailing Address - Fax:
Practice Address - Street 1:2310 CRAVEN ST BLDG 3230
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5596
Practice Address - Country:US
Practice Address - Phone:619-532-7935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist