Provider Demographics
NPI:1134245145
Name:MATHIS FERRY DENTAL ASSOCIATES, INC.
Entity type:Organization
Organization Name:MATHIS FERRY DENTAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:KLATT
Authorized Official - Last Name:DEPAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-345-2307
Mailing Address - Street 1:701 LEADER LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8152
Mailing Address - Country:US
Mailing Address - Phone:843-345-2307
Mailing Address - Fax:843-881-3161
Practice Address - Street 1:701 LEADER LN
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8152
Practice Address - Country:US
Practice Address - Phone:843-345-2307
Practice Address - Fax:843-881-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC025291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9806Medicaid
SC488297OtherUNITED CONCORDIA