Provider Demographics
NPI:1558566737
Name:BETITA, GINA MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:MARIE
Last Name:BETITA
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 1:144 STONY POINT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4122
Mailing Address - Country:US
Mailing Address - Phone:707-521-4600
Mailing Address - Fax:
Practice Address - Street 1:144 STONY POINT RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401
Practice Address - Country:US
Practice Address - Phone:818-319-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA562151223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice