Provider Demographics
NPI:1598372476
Name:MEDIGE, MARY B
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:MEDIGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 DENTAL SQUADRON/SGDD
Mailing Address - Street 2:1055 E. STEWART BLDG 2018
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80925
Mailing Address - Country:US
Mailing Address - Phone:719-566-1333
Mailing Address - Fax:
Practice Address - Street 1:21 DENTAL SQUADRON/SGDD
Practice Address - Street 2:1055 E. STEWART BLDG 2018
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80925
Practice Address - Country:US
Practice Address - Phone:719-566-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant