Basic Information
| Provider Information | |||||||||
| NPI: | 1043506074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHEW | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2529 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787045466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129789865 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2529 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787045466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129789865 | ||||||||
| FaxNumber: | 5129789558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 27123 | TX | Y | Dental Providers | Dentist |
No ID Information.