Provider Demographics
NPI:1750497004
Name:MATHESON, ROBERT L (DENTIST)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:MATHESON
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9033 BASELINE ROAD, SUITE B
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-948-9333
Mailing Address - Fax:909-948-9330
Practice Address - Street 1:9033 BASELINE ROAD, SUITE B
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-948-9333
Practice Address - Fax:909-948-9330
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39682122300000X
CA71095547339682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist