Provider Demographics
NPI:1194953992
Name:MYNSBERGE, MATTHEW RYAN (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
Last Name:MYNSBERGE
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 1:1331 S ELISEO DR
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2010
Mailing Address - Country:US
Mailing Address - Phone:415-461-1150
Mailing Address - Fax:
Practice Address - Street 1:1331 S ELISEO DR
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2010
Practice Address - Country:US
Practice Address - Phone:415-461-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA621801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery