Provider Demographics
NPI:1669793857
Name:DIERCKS, MATTHEW AARON (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:AARON
Last Name:DIERCKS
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 1:15951 LOS GATOS BLVD
Mailing Address - Street 2:STE 8
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-3428
Mailing Address - Country:US
Mailing Address - Phone:408-402-0900
Mailing Address - Fax:402-402-0922
Practice Address - Street 1:15951 LOS GATOS BLVD
Practice Address - Street 2:STE 8
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-3428
Practice Address - Country:US
Practice Address - Phone:408-402-0900
Practice Address - Fax:402-402-0922
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist