Provider Demographics
NPI:1710447388
Name:MATENGENZARA, CHENGETAI BEVERLY
Entity Type:Individual
Prefix:
First Name:CHENGETAI
Middle Name:BEVERLY
Last Name:MATENGENZARA
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 1:18950 MARSH LN APT 208
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-2157
Mailing Address - Country:US
Mailing Address - Phone:214-659-1138
Mailing Address - Fax:
Practice Address - Street 1:18950 MARSH LN APT 208
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-2157
Practice Address - Country:US
Practice Address - Phone:214-659-1138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier