Provider Demographics
NPI:1134323066
Name:MATESKON, JOHN V (LD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:V
Last Name:MATESKON
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 DURSTON RD
Mailing Address - Street 2:UNIT 32
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-2805
Mailing Address - Country:US
Mailing Address - Phone:406-586-6569
Mailing Address - Fax:
Practice Address - Street 1:2149 DURSTON RD
Practice Address - Street 2:UNIT 32
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-2805
Practice Address - Country:US
Practice Address - Phone:406-586-6569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0150076Medicaid