1790035145 NPI number — ANTHONY MARINO D.D.S., M.S. PROFESSIONAL CORORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790035145 NPI number — ANTHONY MARINO D.D.S., M.S. PROFESSIONAL CORORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTHONY MARINO D.D.S., M.S. PROFESSIONAL CORORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790035145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
290 ALAMO DRIVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
VACAVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95688-4245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-448-6271
Provider Business Mailing Address Fax Number:
707-448-4742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 EMPIRE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94533-5707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-448-6271
Provider Business Practice Location Address Fax Number:
707-448-4742
Provider Enumeration Date:
09/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RE
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
COREN
Authorized Official Title or Position:
RDA / FRONT OFFICE ASSISTANT
Authorized Official Telephone Number:
707-448-6271

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  34521 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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