Provider Demographics
NPI:1821755596
Name:MATHIALAGAN, NEVATHA (DDS)
Entity Type:Individual
Prefix:
First Name:NEVATHA
Middle Name:
Last Name:MATHIALAGAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 DARROWS CT
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1256
Mailing Address - Country:US
Mailing Address - Phone:314-550-5528
Mailing Address - Fax:
Practice Address - Street 1:675 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2732
Practice Address - Country:US
Practice Address - Phone:860-347-6971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13248122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist