Healthcare Provider Details

I. General information

NPI: 1922128321
Provider Name (Legal Business Name): MATTHEW EDWARD DUDZIAK DDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8112 MILLIKEN AVE SUITE 102
RANCHO CUCAMONGA CA
91730-7471
US

IV. Provider business mailing address

8112 MILLIKEN AVE SUITE 102
RANCHO CUCAMONGA CA
91730-7471
US

V. Phone/Fax

Practice location:
  • Phone: 909-581-7761
  • Fax: 909-581-7766
Mailing address:
  • Phone: 909-581-7761
  • Fax: 909-581-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5440
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberMD428786
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA98904
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberMD200551
License Number StateLA
# 5
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number73
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: