Provider Demographics
NPI:1487773198
Name:BETANCOURT, MAYRA GEORGINA (DDS)
Entity type:Individual
Prefix:DR
First Name:MAYRA
Middle Name:GEORGINA
Last Name:BETANCOURT
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 1:17701 NW 78TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-3629
Mailing Address - Country:US
Mailing Address - Phone:305-826-2758
Mailing Address - Fax:305-826-2787
Practice Address - Street 1:17701 NW 78TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-3629
Practice Address - Country:US
Practice Address - Phone:305-826-2758
Practice Address - Fax:305-826-2787
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00126551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice