Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 21034 | CA |
NPI | 1003948563 |
---|---|
Provider Name | Dr. Charles Albert Mattison |
First Address | Inglewood, CA 90302-1501 |
Second Address | Inglewood, CA 90302-1501 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B21034 01 | DENTICAL (01) | CA |