Provider Demographics
NPI:1114059706
Name:KENT M. MATTISON, D.M.D., P.C.
Entity Type:Organization
Organization Name:KENT M. MATTISON, D.M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATTISON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-972-4666
Mailing Address - Street 1:2381 MAIN ST E STE B
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3358
Mailing Address - Country:US
Mailing Address - Phone:770-972-4666
Mailing Address - Fax:770-972-9054
Practice Address - Street 1:2381 MAIN ST E STE B
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3358
Practice Address - Country:US
Practice Address - Phone:770-972-4666
Practice Address - Fax:770-972-9054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0082841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty