Provider Demographics
NPI:1720246473
Name:MATIASEVICH, BRADFORD DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:DAVID
Last Name:MATIASEVICH
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 1:256 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-3139
Mailing Address - Country:US
Mailing Address - Phone:831-722-4666
Mailing Address - Fax:831-728-0750
Practice Address - Street 1:256 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3139
Practice Address - Country:US
Practice Address - Phone:831-722-4666
Practice Address - Fax:831-728-0750
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABM46643122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist