Provider Demographics
NPI:1558465880
Name:EYDELMAN, MAYA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAYA
Middle Name:
Last Name:EYDELMAN
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 1:3504 BERING DR
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-4575
Mailing Address - Country:US
Mailing Address - Phone:347-256-2208
Mailing Address - Fax:
Practice Address - Street 1:3504 BERING DRIVE
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-4575
Practice Address - Country:US
Practice Address - Phone:347-256-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049447122300000X
NJ22DI02157000122300000X
CA57852122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02289458Medicaid