Provider Demographics
NPI:1093872707
Name:MATHISEN, JOHN RANDALL SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RANDALL
Last Name:MATHISEN
Suffix:SR
Gender:M
Credentials:DDS
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Mailing Address - Street 1:2075 FOREST AVE
Mailing Address - Street 2:#6
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4812
Mailing Address - Country:US
Mailing Address - Phone:408-287-3892
Mailing Address - Fax:408-293-7765
Practice Address - Street 1:2075 FOREST AVE
Practice Address - Street 2:#6
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4812
Practice Address - Country:US
Practice Address - Phone:408-287-3892
Practice Address - Fax:408-293-7765
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CA212711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice