Provider Demographics
NPI:1306809082
Name:MATHA, AVINASH (DDS)
Entity type:Individual
Prefix:
First Name:AVINASH
Middle Name:
Last Name:MATHA
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 1:707 BIELENBERG DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1426
Mailing Address - Country:US
Mailing Address - Phone:651-964-3747
Mailing Address - Fax:
Practice Address - Street 1:707 BIELENBERG DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1426
Practice Address - Country:US
Practice Address - Phone:651-964-3747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice