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General NPI Number Information
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NPI Number | 1053697201
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Entity Type | Individual
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Provider Name | KISMET MAYO DENTURIST
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Gender | Female
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Dates
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Enumeration Date | 11/01/2011
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Last Update Date | 11/01/2011
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Provider Practice Location Address
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Address Line | 1041 CHETCO AVE
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City | BROOKINGS
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State | OR
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Zip | 97415-7153
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Country | US
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Telephone | 541-412-8000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6459
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City | BROOKINGS
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State | OR
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Zip | 97415-0279
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Country | US
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Telephone | 541-412-8000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122400000X
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Taxonomy Name | Denturist
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License Number | DT-DO-10131106
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License Number State | OR
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