Healthcare Provider Details

I. General information

NPI: 1447510284
Provider Name (Legal Business Name): MICHELLE RENEE MATHIESON DMD, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2012
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3005 ROYAL BLVD S SUITE 200
ALPHARETTA GA
30022-1409
US

IV. Provider business mailing address

10930 CRABAPPLE RD STE 106
ROSWELL GA
30075-5825
US

V. Phone/Fax

Practice location:
  • Phone: 770-680-2335
  • Fax: 770-710-0317
Mailing address:
  • Phone: 678-352-1090
  • Fax: 678-974-1993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401413477
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN014503
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: