Provider Demographics
NPI:1164574901
Name:SAN LUIS, MYRA GUEVARRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:GUEVARRA
Last Name:SAN LUIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21471 FOOTHILL BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541
Mailing Address - Country:US
Mailing Address - Phone:510-537-6175
Mailing Address - Fax:510-537-6170
Practice Address - Street 1:21471 FOOTHILL BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541
Practice Address - Country:US
Practice Address - Phone:510-537-6175
Practice Address - Fax:510-537-6170
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50365122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist