Provider Demographics
NPI:1760679716
Name:PATUWO, MARY H (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:H
Last Name:PATUWO
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 1:14796 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-4217
Mailing Address - Country:US
Mailing Address - Phone:714-562-0402
Mailing Address - Fax:714-562-0248
Practice Address - Street 1:14796 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-4217
Practice Address - Country:US
Practice Address - Phone:714-562-0402
Practice Address - Fax:714-562-0248
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB36411-01122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1659423226OtherCORP NPI