Provider Demographics
NPI:1053697201
Name:MAYO, KISMET (DENTURIST)
Entity type:Individual
Prefix:MRS
First Name:KISMET
Middle Name:
Last Name:MAYO
Suffix:
Gender:F
Credentials:DENTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6459
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0279
Mailing Address - Country:US
Mailing Address - Phone:541-412-8000
Mailing Address - Fax:
Practice Address - Street 1:1041 CHETCO AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-7153
Practice Address - Country:US
Practice Address - Phone:541-412-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10131106122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist