Provider Demographics
NPI:1578245197
Name:MATHIS, GWENDOLYN BROOKE (RDH)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:BROOKE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 SHALLOWFORD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-5406
Mailing Address - Country:US
Mailing Address - Phone:423-893-6500
Mailing Address - Fax:
Practice Address - Street 1:6401 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-5406
Practice Address - Country:US
Practice Address - Phone:423-893-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7731124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist