Provider Demographics
NPI:1124579909
Name:DESPOTIDES, BIANCA ANDREA (ND)
Entity Type:Individual
Prefix:DR
First Name:BIANCA
Middle Name:ANDREA
Last Name:DESPOTIDES
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 N KIRBY ST
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582-3763
Mailing Address - Country:US
Mailing Address - Phone:480-381-3857
Mailing Address - Fax:
Practice Address - Street 1:1695 S SAN JACINTO AVE
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5103
Practice Address - Country:US
Practice Address - Phone:480-381-3857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND-911175F00000X
AZ16-1594175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath