Provider Demographics
NPI:1104039809
Name:MATHESON, MICHAEL KENT (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KENT
Last Name:MATHESON
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 1:3939 WASATCH BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2216
Mailing Address - Country:US
Mailing Address - Phone:801-424-0027
Mailing Address - Fax:801-424-0029
Practice Address - Street 1:3939 WASATCH BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2216
Practice Address - Country:US
Practice Address - Phone:801-424-0027
Practice Address - Fax:801-424-0029
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT362747-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist