Provider Demographics
NPI:1235242306
Name:MARDESICH, VINCENT MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:MATTHEW
Last Name:MARDESICH
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 1:1360 W 6TH ST
Mailing Address - Street 2:STE. 210 ,WEST BUILDING
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-514-1000
Mailing Address - Fax:310-514-1005
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:STE. 210 ,WEST BUILDING
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-514-1000
Practice Address - Fax:310-514-1005
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA354301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice