Provider Demographics
NPI:1891233722
Name:MATHISON, MICA (DMD)
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:
Last Name:MATHISON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2946 WINFIELD DUNN PKWY
Mailing Address - Street 2:
Mailing Address - City:KODAK
Mailing Address - State:TN
Mailing Address - Zip Code:37764-4306
Mailing Address - Country:US
Mailing Address - Phone:865-465-7058
Mailing Address - Fax:
Practice Address - Street 1:2946 WINFIELD DUNN PKWY
Practice Address - Street 2:
Practice Address - City:KODAK
Practice Address - State:TN
Practice Address - Zip Code:37764-4306
Practice Address - Country:US
Practice Address - Phone:865-465-7058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-11
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0157191223G0001X
390200000X
TNDS00000105811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program