Provider Demographics
NPI:1366651960
Name:MATHIS, NORMAN D (DDS)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:D
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 1:508 CAJON ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5904
Mailing Address - Country:US
Mailing Address - Phone:909-793-2024
Mailing Address - Fax:909-793-2026
Practice Address - Street 1:508 CAJON ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5904
Practice Address - Country:US
Practice Address - Phone:909-793-2024
Practice Address - Fax:909-793-2026
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00348771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice