Healthcare Provider Details

I. General information

NPI: 1255882858
Provider Name (Legal Business Name): JULIE MARIE GAMEZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE MARIE BERG

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10566 N HIGHWAY 191
ELFRIDA AZ
85610-9021
US

IV. Provider business mailing address

155 CALLE PORTAL STE 100
SIERRA VISTA AZ
85635-2900
US

V. Phone/Fax

Practice location:
  • Phone: 520-642-2222
  • Fax:
Mailing address:
  • Phone: 520-459-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH04257
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: