Provider Demographics
NPI:1154733640
Name:GENDLIN, MAYA ALEXANDRA (DDS)
Entity type:Individual
Prefix:DR
First Name:MAYA
Middle Name:ALEXANDRA
Last Name:GENDLIN
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 1:2548 PERRY CT
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-2035
Mailing Address - Country:US
Mailing Address - Phone:219-776-0680
Mailing Address - Fax:
Practice Address - Street 1:2548 PERRY CT
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-2035
Practice Address - Country:US
Practice Address - Phone:219-776-0680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 20610122300000X
IL019030131122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist