Basic Information
Provider Information
NPI: 1487706339
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DEFAY
FirstName: MYRIAM
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 41221 BROWN RD
Address2:  
City: FALL RIVER MILLS
State: CA
PostalCode: 960289726
CountryCode: US
TelephoneNumber: 5303367155
FaxNumber:  
Practice Location
Address1: 554-850 MEDICAL CENTER DRIVE
Address2:  
City: BIEBER
State: CA
PostalCode: 96009
CountryCode: US
TelephoneNumber: 5302945629
FaxNumber: 5302945392
Other Information
ProviderEnumerationDate: 01/18/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X52977CAY Dental ProvidersDentist 

No ID Information.


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