Provider Demographics
NPI:1205809605
Name:MATHES, JOHN D (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:MATHES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 N MAIN
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124
Mailing Address - Country:US
Mailing Address - Phone:620-672-9922
Mailing Address - Fax:620-672-9966
Practice Address - Street 1:603 N MAIN
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124
Practice Address - Country:US
Practice Address - Phone:620-672-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5971122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0000116868OtherBLUE CROSS BLUE SHIELD