Provider Demographics
NPI:1538238779
Name:MATHESON, STEPHEN R (DDS PS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:MATHESON
Suffix:
Gender:M
Credentials:DDS PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 W CLEARWATER AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336
Mailing Address - Country:US
Mailing Address - Phone:509-783-5000
Mailing Address - Fax:509-783-8349
Practice Address - Street 1:5000 W CLEARWATER AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-783-5000
Practice Address - Fax:509-783-8349
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00004645122300000X
WADE00008483126800000X
WADE00010578126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
4645OtherWDS
408285OtherUNITED CONCORDIA
WA5510003Medicaid