Provider Demographics
NPI:1093898215
Name:MATTSON, JAMES FREDERICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:FREDERICK
Last Name:MATTSON
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:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-4521
Mailing Address - Country:US
Mailing Address - Phone:707-964-5616
Mailing Address - Fax:707-964-5917
Practice Address - Street 1:499 CHESTNUT ST
Practice Address - Street 2:SUITE C
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-4521
Practice Address - Country:US
Practice Address - Phone:707-964-5616
Practice Address - Fax:707-964-5917
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27798122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2227798Medicaid
CACOAST5616OtherMPIN