Provider Demographics
NPI:1437440260
Name:BAZAVILVAZO, MAYRA (DMD)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:BAZAVILVAZO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 AVOCADO AVE
Mailing Address - Street 2:502
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7720
Mailing Address - Country:US
Mailing Address - Phone:949-640-9554
Mailing Address - Fax:
Practice Address - Street 1:1012 BRIOSO DR STE 105
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-4544
Practice Address - Country:US
Practice Address - Phone:305-298-8797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA602571223P0300X
FLDN173001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics