Basic Information
| Provider Information | |||||||||
| NPI: | 1477834968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASEMILLER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11330 SAN JUAN ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923543329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016404606 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2878 CAMPUS PKWY STE 1 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925070945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515710011 | ||||||||
| FaxNumber: | 9515710012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2011 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 60742 | CA | Y | Dental Providers | Dentist |
No ID Information.