Provider Demographics
NPI:1114956315
Name:THEVA, MATHI
Entity Type:Individual
Prefix:
First Name:MATHI
Middle Name:
Last Name:THEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 CANAVAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184
Mailing Address - Country:US
Mailing Address - Phone:781-849-3422
Mailing Address - Fax:
Practice Address - Street 1:200 WEST GATE DR
Practice Address - Street 2:SUITE 135 UNIDENT DENTAL CENTER
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-583-3840
Practice Address - Fax:508-559-6577
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17809122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0273449Medicaid