Provider Demographics
NPI:1902151491
Name:MATHEW, ANIT MERRY
Entity Type:Individual
Prefix:
First Name:ANIT
Middle Name:MERRY
Last Name:MATHEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14410 SE PETROVITSKY RD
Mailing Address - Street 2:#113
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058
Mailing Address - Country:US
Mailing Address - Phone:626-253-1734
Mailing Address - Fax:
Practice Address - Street 1:14410 SE PETROVITSKY RD
Practice Address - Street 2:#113
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058
Practice Address - Country:US
Practice Address - Phone:626-253-1734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60573228122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist