Provider Demographics
NPI:1124305875
Name:MATHIAS, RICHARD (DMD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MATHIAS
Suffix:
Gender:M
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:255 HIGHWAY 187
Practice Address - Street 2:
Practice Address - City:HATCH
Practice Address - State:NM
Practice Address - Zip Code:87937-0370
Practice Address - Country:US
Practice Address - Phone:575-267-3088
Practice Address - Fax:575-267-4565
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3617122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist