Provider Demographics
NPI:1073668430
Name:ZAVALA, MARIBEL G (PTDA)
Entity Type:Individual
Prefix:
First Name:MARIBEL
Middle Name:G
Last Name:ZAVALA
Suffix:
Gender:F
Credentials:PTDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W JERSEY ST
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-1911
Mailing Address - Country:US
Mailing Address - Phone:503-722-7571
Mailing Address - Fax:
Practice Address - Street 1:10209 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9782
Practice Address - Country:US
Practice Address - Phone:503-353-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR113062126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR834Medicare UPIN