Provider Demographics
NPI:1992914196
Name:PERIO IMPLANT HEALTH PROFESSIONALS
Entity type:Organization
Organization Name:PERIO IMPLANT HEALTH PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MATOSKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-481-0664
Mailing Address - Street 1:1127 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1110
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-3901
Mailing Address - Country:US
Mailing Address - Phone:213-481-0664
Mailing Address - Fax:213-481-2902
Practice Address - Street 1:1127 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3901
Practice Address - Country:US
Practice Address - Phone:213-481-0664
Practice Address - Fax:213-481-2902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260911223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty