Provider Demographics
NPI:1083371876
Name:MATHEW, JAYCE (DDS)
Entity Type:Individual
Prefix:
First Name:JAYCE
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 S CLAYTON ST APT 4306
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5782
Mailing Address - Country:US
Mailing Address - Phone:516-884-5418
Mailing Address - Fax:
Practice Address - Street 1:30 S CLAYTON ST APT 4306
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5782
Practice Address - Country:US
Practice Address - Phone:516-884-5418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
GADN1225581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program