Provider Demographics
NPI:1154858041
Name:MATHIS, ANDREW THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:THOMAS
Last Name:MATHIS
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 1:1529 SHIRLEY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-1443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 DS/SGXD
Practice Address - Street 2:UNIT 5024
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96319-5024
Practice Address - Country:US
Practice Address - Phone:315-226-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9018122300000X, 1223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery