Provider Demographics
NPI:1871106039
Name:WASILEWSKI, MATTHEW RAYMOND (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RAYMOND
Last Name:WASILEWSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 ANTONSON LN NE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-5502
Mailing Address - Country:US
Mailing Address - Phone:480-389-8797
Mailing Address - Fax:
Practice Address - Street 1:1 BOONE RD
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-1898
Practice Address - Country:US
Practice Address - Phone:360-475-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1051001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice