Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | DN015216 | GA |
NPI | 1285083527 |
---|---|
Provider Name | Dr. Dexter Witherington Mattox |
First Address | University Heights, OH 44118-4451 |
Second Address | St Simons Island, GA 31522-6604 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2016 |
Last Update Date | 29/03/2021 |