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General NPI Number Information
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NPI Number | 1245488576
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Entity Type | Individual
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Provider Name | VICTORIA SIMONE MATHIS D.D.S
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Gender | Female
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Dates
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Enumeration Date | 08/28/2008
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Last Update Date | 06/18/2012
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Provider Practice Location Address
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Address Line | 5124 STAGE RD SUITE C2
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City | MEMPHIS
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State | TN
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Zip | 38134-3164
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Country | US
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Telephone | 901-373-5433
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Fax | 901-373-7322
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Provider Business Mailing Address
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Address Line | 5124 STAGE RD SUITE C2
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City | MEMPHIS
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State | TN
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Zip | 38134-3164
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Country | US
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Telephone | 901-373-5433
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Fax | 901-373-7322
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DS8905
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License Number State | TN
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