Provider Demographics
NPI:1700350485
Name:ARCHAMBAULT, KATYA (DMD)
Entity Type:Individual
Prefix:
First Name:KATYA
Middle Name:
Last Name:ARCHAMBAULT
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 1:9245 REGENTS RD UNIT M208
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9266
Mailing Address - Country:US
Mailing Address - Phone:310-307-6623
Mailing Address - Fax:
Practice Address - Street 1:9245 REGENTS RD UNIT M208
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9266
Practice Address - Country:US
Practice Address - Phone:310-307-6623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS652781223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology