Provider Demographics
NPI:1205197720
Name:MATHEW, TREASA (DMD)
Entity type:Individual
Prefix:DR
First Name:TREASA
Middle Name:
Last Name:MATHEW
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 1:106 COLONY PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-7233
Mailing Address - Country:US
Mailing Address - Phone:508-830-0411
Mailing Address - Fax:
Practice Address - Street 1:45 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171-2610
Practice Address - Country:US
Practice Address - Phone:617-773-9902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18559641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN1855964OtherTHE COMMONWEALTH OF MASSACHUSETTS HEALTH PROFESSIONS LICENSURE