Provider Demographics
NPI:1063424232
Name:MATHISON, BRIAN COLE (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:COLE
Last Name:MATHISON
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 1:4742 AMBER VALLEY PKWY S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8614
Mailing Address - Country:US
Mailing Address - Phone:701-356-3999
Mailing Address - Fax:701-356-4088
Practice Address - Street 1:4742 AMBER VALLEY PKWY S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8614
Practice Address - Country:US
Practice Address - Phone:701-356-3999
Practice Address - Fax:701-356-4088
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1887122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND971887OtherDENTAL SERVIC CORP