MEDICARE: DR. ASHLEY DIVYA MATHEW DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	40204	TX

General Provider Information

NPI Number	:	1689441461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ASHLEY DIVYA MATHEW DDS

Provider Business Mailing Address
First Line	:	3162 HOLLY HALL ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-4135
Country	:	US
Telephone Number	:	956-662-9322
Fax Number	:

Provider Business Practice Location Address
First Line	:	1920 WEST LOOP
Second Line	:
City	:	EL CAMPO
State	:	TX
Zip	:	77437-8007
Country	:	US
Telephone Number	:	979-475-1227
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2023
Last Update Date	:	12/14/2023

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