Provider Demographics
NPI:1851915789
Name:DESIDERIO, MATTHEW (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:DESIDERIO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 15TH ST APT 1504
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-7698
Mailing Address - Country:US
Mailing Address - Phone:609-781-5660
Mailing Address - Fax:
Practice Address - Street 1:3767 AVOCADO BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7301
Practice Address - Country:US
Practice Address - Phone:619-729-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-06
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106958122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist