Healthcare Provider Details

I. General information

NPI: 1154858041
Provider Name (Legal Business Name): ANDREW THOMAS MATHIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 10/11/2026
Certification Date: 10/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 W PERIMETER RD BLDG 1060
JB ANDREWS MD
20762-6602
US

IV. Provider business mailing address

1529 SHIRLEY ST
COLUMBIA SC
29205-1443
US

V. Phone/Fax

Practice location:
  • Phone: 240-612-3900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9018
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9018
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number18894
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: