Provider Demographics
NPI:1922705029
Name:MGDVELADZE, EMILIIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:EMILIIA
Middle Name:
Last Name:MGDVELADZE
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 1:680 LONGBRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-2306
Mailing Address - Country:US
Mailing Address - Phone:424-216-0718
Mailing Address - Fax:
Practice Address - Street 1:2205 S BROADWAY OFC 122
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7813
Practice Address - Country:US
Practice Address - Phone:805-863-9430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1085681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice