Provider Demographics
NPI:1043664824
Name:BEZUAYEHU, FEKERTE (RDHAP)
Entity Type:Individual
Prefix:
First Name:FEKERTE
Middle Name:
Last Name:BEZUAYEHU
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4076 MAYBELLE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-2216
Mailing Address - Country:US
Mailing Address - Phone:510-773-7070
Mailing Address - Fax:
Practice Address - Street 1:325 11TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-3105
Practice Address - Country:US
Practice Address - Phone:510-773-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP 615124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist