Provider Demographics
NPI:1770117368
Name:MAYEDA, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MAYEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15804 W 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80403-2145
Mailing Address - Country:US
Mailing Address - Phone:303-990-2989
Mailing Address - Fax:
Practice Address - Street 1:360 PEAK ONE DR STE 325
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-5948
Practice Address - Country:US
Practice Address - Phone:970-668-4045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002046701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty