Provider Demographics
NPI:1336298058
Name:KRIEWALDT, MATTHEW B (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:B
Last Name:KRIEWALDT
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 1:3100 6TH AVE UNIT 502
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5812
Mailing Address - Country:US
Mailing Address - Phone:619-701-3900
Mailing Address - Fax:
Practice Address - Street 1:2310 CRAVEN ST BLDG 3230
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5596
Practice Address - Country:US
Practice Address - Phone:619-701-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6903-151223X0400X
CA555211223X0400X
VA04014137011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics