Provider Demographics
NPI:1346467511
Name:BARRY R. MATHESON, DDS, MSD PC
Entity Type:Organization
Organization Name:BARRY R. MATHESON, DDS, MSD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MATHESON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:276-669-1231
Mailing Address - Street 1:817 GATE CITY HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201
Mailing Address - Country:US
Mailing Address - Phone:276-669-1231
Mailing Address - Fax:276-466-6872
Practice Address - Street 1:817 GATE CITY HIGHWAY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201
Practice Address - Country:US
Practice Address - Phone:276-669-1231
Practice Address - Fax:276-466-6872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010066031223P0300X
TNDS00000050571223P0300X
TX148751223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU51469Medicare UPIN