Basic Information
| Provider Information | |||||||||
| NPI: | 1083381412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTHEWS-PENROD | ||||||||
| FirstName: | CANDICE MARISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 E SHOW LOW LAKE RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285374300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 378 E 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | EAGAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859259763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285374300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2021 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | H008271 | AZ | Y | Dental Providers | Dental Hygienist |
No ID Information.