Provider Demographics
NPI:1053399196
Name:MATT GORHAM JR., D.D.S., P.C.
Entity type:Organization
Organization Name:MATT GORHAM JR., D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:J
Authorized Official - Last Name:GORHAM
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-327-4914
Mailing Address - Street 1:124 30TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1308
Mailing Address - Country:US
Mailing Address - Phone:615-327-4914
Mailing Address - Fax:615-327-3892
Practice Address - Street 1:124 30TH AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1308
Practice Address - Country:US
Practice Address - Phone:615-327-4914
Practice Address - Fax:615-327-3892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4826122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty