=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285889808
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW DAVID DE LA RIONDA DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2008
-----------------------------------------------------
Last Update Date | 08/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17175 VENTURA BLVD
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-4050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-3488
-----------------------------------------------------
Fax | 818-788-4388
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17175 VENTURA BLVD
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-4050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-3488
-----------------------------------------------------
Fax | 818-788-4388
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 57609
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------