Provider Demographics
NPI:1144468554
Name:PEBDANI, GERALDINE A (RDH)
Entity type:Individual
Prefix:MS
First Name:GERALDINE
Middle Name:A
Last Name:PEBDANI
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 HAMILTON RD
Mailing Address - Street 2:USA DENTAL ACTIVITY
Mailing Address - City:FT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503
Mailing Address - Country:US
Mailing Address - Phone:580-442-3905
Mailing Address - Fax:580-442-4002
Practice Address - Street 1:652 HAMILTON RD
Practice Address - Street 2:USA DENTAL ACTIVITY
Practice Address - City:FT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503
Practice Address - Country:US
Practice Address - Phone:580-442-3905
Practice Address - Fax:580-442-4002
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00006978124Q00000X
CA26454124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist