Healthcare Provider Details

I. General information

NPI: 1457411167
Provider Name (Legal Business Name): KATRINA CHAUNDANI MATTISON D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 MAIN ST
PROSPECT HILL NC
27314-9438
US

IV. Provider business mailing address

415 TIGHFIELD DRIVE
MEBANE NC
27302
US

V. Phone/Fax

Practice location:
  • Phone: 336-562-3123
  • Fax:
Mailing address:
  • Phone: 919-563-1453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number8099
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: