Provider Demographics
NPI:1457567133
Name:CORPUS, MARY ANN AREVALO (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:AREVALO
Last Name:CORPUS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15720 VENTURA BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2983
Mailing Address - Country:US
Mailing Address - Phone:818-788-7181
Mailing Address - Fax:818-907-1891
Practice Address - Street 1:15720 VENTURA BLVD STE 301
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2983
Practice Address - Country:US
Practice Address - Phone:818-788-7181
Practice Address - Fax:818-907-1891
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41381122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist