Provider Demographics
NPI:1851496954
Name:MATHESON, ROSS RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:RICHARD
Last Name:MATHESON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 N HANSELMAN ST
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-1201
Mailing Address - Country:US
Mailing Address - Phone:248-605-1227
Mailing Address - Fax:
Practice Address - Street 1:124 N HANSELMAN ST
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-1201
Practice Address - Country:US
Practice Address - Phone:248-605-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist