Provider Demographics
NPI:1578784120
Name:BESERRA, MADELEINE (RDH)
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
Last Name:BESERRA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 2336
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-2336
Mailing Address - Country:US
Mailing Address - Phone:970-264-9436
Mailing Address - Fax:970-264-9436
Practice Address - Street 1:101 PAGOSA STREET
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-264-9436
Practice Address - Fax:970-264-9436
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO903251124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist