Provider Demographics
NPI:1104845270
Name:PEDIATRIC DENTISTRY OF MATTHEWS
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF MATTHEWS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:METHENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-847-4717
Mailing Address - Street 1:1340 MATTHEWS TOWNSHIP PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5580
Mailing Address - Country:US
Mailing Address - Phone:704-847-4717
Mailing Address - Fax:
Practice Address - Street 1:1340 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5580
Practice Address - Country:US
Practice Address - Phone:704-847-4717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC48471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890103XMedicaid
NCU 39041Medicare UPIN