Provider Demographics
NPI:1366686099
Name:LEDESMA, MARY CATHERINE (DDLD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CATHERINE
Last Name:LEDESMA
Suffix:
Gender:F
Credentials:DDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3969 STANLEY LN S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4762
Mailing Address - Country:US
Mailing Address - Phone:503-362-6264
Mailing Address - Fax:
Practice Address - Street 1:3969 STANLEY LN S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4762
Practice Address - Country:US
Practice Address - Phone:503-362-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10125322122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist