Provider Demographics
NPI:1417160904
Name:MATIASEVICH, ROBERT N SR (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:N
Last Name:MATIASEVICH
Suffix:SR
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 1:1775 DOMINICAN WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065
Mailing Address - Country:US
Mailing Address - Phone:831-476-7272
Mailing Address - Fax:831-476-1446
Practice Address - Street 1:1775 DOMINICAN WAY
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065
Practice Address - Country:US
Practice Address - Phone:831-476-7272
Practice Address - Fax:831-476-1446
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist