Provider Demographics
NPI:1700906492
Name:PALANCA-BEVERIDGE, MARIQUITA MARQUINEZ (DDS)
Entity Type:Individual
Prefix:
First Name:MARIQUITA
Middle Name:MARQUINEZ
Last Name:PALANCA-BEVERIDGE
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 1:8280 MICHIGAN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3826
Mailing Address - Country:US
Mailing Address - Phone:317-337-0233
Mailing Address - Fax:317-337-0234
Practice Address - Street 1:8280 MICHIGAN RD
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-3826
Practice Address - Country:US
Practice Address - Phone:317-337-0233
Practice Address - Fax:317-337-0234
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120095221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice