Provider Demographics
NPI:1255021028
Name:CAMACHO, MAYRA (DMD)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:CAMACHO
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 1:27188 SUN CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92586-5505
Mailing Address - Country:US
Mailing Address - Phone:951-679-1661
Mailing Address - Fax:
Practice Address - Street 1:27188 SUN CITY BLVD
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92586-5505
Practice Address - Country:US
Practice Address - Phone:951-679-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110164122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program