Healthcare Provider Details

I. General information

NPI: 1073761730
Provider Name (Legal Business Name): MARISELA M. BEDOYA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5855 E STILL CIR
MESA AZ
85206-3618
US

IV. Provider business mailing address

5850 E STILL CIR
MESA AZ
85206-3618
US

V. Phone/Fax

Practice location:
  • Phone: 480-248-8132
  • Fax: 480-248-8117
Mailing address:
  • Phone: 480-219-6183
  • Fax: 480-219-6080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD7339
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: