Provider Demographics
NPI:1528125325
Name:MATTSON, VIRGINIA PADUA (DMD)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:PADUA
Last Name:MATTSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11717 BERNARDO PLAZA CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2409
Mailing Address - Country:US
Mailing Address - Phone:858-673-1633
Mailing Address - Fax:858-673-0093
Practice Address - Street 1:11717 BERNARDO PLAZA CT
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2409
Practice Address - Country:US
Practice Address - Phone:858-673-1633
Practice Address - Fax:858-673-0093
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA413501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice