Provider Demographics
NPI:1083381412
Name:MATTHEWS-PENROD, CANDICE MARISSA (RDH)
Entity Type:Individual
Prefix:MS
First Name:CANDICE MARISSA
Middle Name:
Last Name:MATTHEWS-PENROD
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 E SHOW LOW LAKE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7955
Mailing Address - Country:US
Mailing Address - Phone:928-537-4300
Mailing Address - Fax:
Practice Address - Street 1:378 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:EAGAR
Practice Address - State:AZ
Practice Address - Zip Code:85925-9763
Practice Address - Country:US
Practice Address - Phone:928-537-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH008271124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist