Provider Demographics
NPI:1861668451
Name:DE MIRZA, BENITA JANINE (DMD)
Entity Type:Individual
Prefix:MS
First Name:BENITA
Middle Name:JANINE
Last Name:DE MIRZA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 F ST STE 260
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2649
Mailing Address - Country:US
Mailing Address - Phone:619-585-8500
Mailing Address - Fax:619-420-0275
Practice Address - Street 1:345 F ST STE 260
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2649
Practice Address - Country:US
Practice Address - Phone:619-585-8500
Practice Address - Fax:619-420-0275
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA564241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry