Provider Demographics
NPI:1649527730
Name:MATHEWS, JACQUELYN P (DMD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:P
Last Name:MATHEWS
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 1:1008 E BRENTRUP DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-4782
Mailing Address - Country:US
Mailing Address - Phone:480-861-5338
Mailing Address - Fax:
Practice Address - Street 1:28451 N VISTANCIA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2090
Practice Address - Country:US
Practice Address - Phone:623-218-6638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6966-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice