Healthcare Provider Details

I. General information

NPI: 1134323066
Provider Name (Legal Business Name): JOHN V MATESKON L.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2149 DURSTON RD UNIT 32
BOZEMAN MT
59718-2805
US

IV. Provider business mailing address

2149 DURSTON RD UNIT 32
BOZEMAN MT
59718-2805
US

V. Phone/Fax

Practice location:
  • Phone: 406-586-6569
  • Fax:
Mailing address:
  • Phone: 406-586-6569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number10
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: