Provider Demographics
NPI:1639396989
Name:MATHESON, BARRY ROBERT (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:ROBERT
Last Name:MATHESON
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
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?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU51469Medicare UPIN