Basic Information
| Provider Information | |||||||||
| NPI: | 1053399196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MATT GORHAM JR., D.D.S., P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 124 30TH AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274914 | ||||||||
| FaxNumber: | 6153273892 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 30TH AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274914 | ||||||||
| FaxNumber: | 6153273892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GORHAM | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153274914 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | D.D.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 4826 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.