Provider Demographics
NPI:1265504997
Name:KIISK, MAT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAT
Middle Name:
Last Name:KIISK
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 1:25 OAKHURST RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-5256
Mailing Address - Country:US
Mailing Address - Phone:415-721-7349
Mailing Address - Fax:
Practice Address - Street 1:3100 19TH AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-2006
Practice Address - Country:US
Practice Address - Phone:415-584-2537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA205491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice