Provider Demographics
NPI:1104167162
Name:MATOSIAN, GEORGE S (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:S
Last Name:MATOSIAN
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 1:8851 CENTER DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3017
Mailing Address - Country:US
Mailing Address - Phone:619-460-6900
Mailing Address - Fax:619-460-6981
Practice Address - Street 1:8851 CENTER DR
Practice Address - Street 2:SUITE 301
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3017
Practice Address - Country:US
Practice Address - Phone:619-460-6900
Practice Address - Fax:619-460-6981
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA248291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
1952487357OtherNPI CORPORATE NUMBER