Provider Demographics
NPI:1750651519
Name:MYRIAM M DEFAY DDS INC.
Entity Type:Organization
Organization Name:MYRIAM M DEFAY DDS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MYRIAM
Authorized Official - Middle Name:MERCEDES
Authorized Official - Last Name:DEFAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-447-9091
Mailing Address - Street 1:644 E UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-1744
Mailing Address - Country:US
Mailing Address - Phone:559-447-9091
Mailing Address - Fax:559-447-9091
Practice Address - Street 1:2665 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-2908
Practice Address - Country:US
Practice Address - Phone:209-358-1577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA529771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty