MEDICARE: MARY L. DIMYAN, DDS.INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	44163	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	44163	OTHER	CA	DENTAL LICENSE

General Provider Information

NPI Number	:	1114000122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY L. DIMYAN, DDS.INC

Provider Business Mailing Address
First Line	:	43 PENINSULA CTR # B
Second Line	:	SUITE #2
City	:	ROLLING HILLS ESTATES
State	:	CA
Zip	:	90274-3506
Country	:	US
Telephone Number	:	310-544-7044
Fax Number	:	310-544-7344

Provider Business Practice Location Address
First Line	:	43 PENINSULA CTR # B
Second Line	:	SUITE #2
City	:	ROLLING HILLS ESTATES
State	:	CA
Zip	:	90274-3506
Country	:	US
Telephone Number	:	310-544-7044
Fax Number	:	310-544-7344

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARY L DIMYAN
Credential	:	D.D.S.
Telephone Number	:	310-544-7044

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	08/22/2020

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