Provider Demographics
NPI:1568653210
Name:DEBANFF, MARYELLEN (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MARYELLEN
Middle Name:
Last Name:DEBANFF
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 1:33694 YUCAIPA BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2074
Mailing Address - Country:US
Mailing Address - Phone:909-797-1077
Mailing Address - Fax:909-797-1189
Practice Address - Street 1:33694 YUCAIPA BLVD STE 3
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2074
Practice Address - Country:US
Practice Address - Phone:909-797-1077
Practice Address - Fax:909-797-1189
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA443041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice