Provider Demographics
NPI:1245329408
Name:MATTINGLY, JAMES R V
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:MATTINGLY
Suffix:V
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LA CASA VIA
Mailing Address - Street 2:STE 202 BLDG 1
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3045
Mailing Address - Country:US
Mailing Address - Phone:925-933-5446
Mailing Address - Fax:925-933-5448
Practice Address - Street 1:130 LA CASA VIA
Practice Address - Street 2:SUITE 202, BLDG. #1
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3045
Practice Address - Country:US
Practice Address - Phone:925-933-5446
Practice Address - Fax:925-933-5448
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA447411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice