Provider Demographics
NPI:1477834968
Name:WASEMILLER, MATTHEW MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MARK
Last Name:WASEMILLER
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 1:11330 SAN JUAN ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3329
Mailing Address - Country:US
Mailing Address - Phone:701-640-4606
Mailing Address - Fax:
Practice Address - Street 1:2878 CAMPUS PKWY STE 1
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0945
Practice Address - Country:US
Practice Address - Phone:951-571-0011
Practice Address - Fax:951-571-0012
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60742122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist