Provider Demographics
NPI:1245488576
Name:MATHIS, VICTORIA SIMONE (DDS)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:SIMONE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:VICTORIA
Other - Middle Name:SIMONE
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:5124 STAGE RD
Mailing Address - Street 2:SUITE C2
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3164
Mailing Address - Country:US
Mailing Address - Phone:901-373-5433
Mailing Address - Fax:901-373-7322
Practice Address - Street 1:5124 STAGE RD
Practice Address - Street 2:SUITE C2
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-3164
Practice Address - Country:US
Practice Address - Phone:901-373-5433
Practice Address - Fax:901-373-7322
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS89051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice