Healthcare Provider Details

I. General information

NPI: 1992914196
Provider Name (Legal Business Name): PERIO IMPLANT HEALTH PROFESSIONALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 WILSHIRE BLVD SUITE 1110
LOS ANGELES CA
90017-3901
US

IV. Provider business mailing address

1127 WILSHIRE BLVD SUITE 1110
LOS ANGELES CA
90017-3901
US

V. Phone/Fax

Practice location:
  • Phone: 213-481-0664
  • Fax: 213-481-2902
Mailing address:
  • Phone: 213-481-0664
  • Fax: 213-481-2902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number26091
License Number StateCA

VIII. Authorized Official

Name: DR. WILLIAM MATOSKA
Title or Position: PERIODONTIST
Credential: D.D.S.
Phone: 213-481-0664