Provider Demographics
NPI:1831483650
Name:MATHEW, MARILYN BETTY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:BETTY
Last Name:MATHEW
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 1:751 MALLET HILL RD
Mailing Address - Street 2:APT 4208
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-4471
Mailing Address - Country:US
Mailing Address - Phone:845-702-0581
Mailing Address - Fax:
Practice Address - Street 1:751 MALLET HILL RD
Practice Address - Street 2:APT 4208
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4471
Practice Address - Country:US
Practice Address - Phone:845-702-0581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001024-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1831483650Medicaid