Provider Demographics
NPI:1396847356
Name:MATHIS, MICHAEL BURGIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BURGIN
Last Name:MATHIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3000 BARDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3009
Mailing Address - Country:US
Mailing Address - Phone:502-451-2212
Mailing Address - Fax:502-456-0849
Practice Address - Street 1:3000 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3009
Practice Address - Country:US
Practice Address - Phone:502-451-2212
Practice Address - Fax:502-456-0849
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY46181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice