Provider Demographics
NPI:1811066541
Name:FUKAMI, MARI CYNTHIA (DMD)
Entity type:Individual
Prefix:
First Name:MARI
Middle Name:CYNTHIA
Last Name:FUKAMI
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 1:5519 E CALLE DEL NORTE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-4554
Mailing Address - Country:US
Mailing Address - Phone:602-750-6533
Mailing Address - Fax:480-302-7900
Practice Address - Street 1:625 W SOUTHERN AVE
Practice Address - Street 2:STE E-145
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5030
Practice Address - Country:US
Practice Address - Phone:480-516-8428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ68151223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDental Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ088348Medicaid