Provider Demographics
NPI:1699704999
Name:MATHI THEVA DMD PC
Entity type:Organization
Organization Name:MATHI THEVA DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:THEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-583-3840
Mailing Address - Street 1:200 WEST GATE DR
Mailing Address - Street 2:SUITE 135
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:508-583-3840
Mailing Address - Fax:508-559-6577
Practice Address - Street 1:200 WEST GATE DR
Practice Address - Street 2:SUITE 135
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-583-3840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9769862Medicaid