Provider Demographics
NPI:1245497932
Name:INLAND EMPIRE ORAL AND MAXILLOFACIAL SURGEONS
Entity type:Organization
Organization Name:INLAND EMPIRE ORAL AND MAXILLOFACIAL SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DUDZIAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:909-581-7761
Mailing Address - Street 1:8112 MILLIKEN AVE
Mailing Address - Street 2:102
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7471
Mailing Address - Country:US
Mailing Address - Phone:909-581-7761
Mailing Address - Fax:909-581-7766
Practice Address - Street 1:8112 MILLIKEN AVE
Practice Address - Street 2:102
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7471
Practice Address - Country:US
Practice Address - Phone:909-581-7761
Practice Address - Fax:909-581-7766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA731223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty