Provider Demographics
NPI:1003989427
Name:FORTIN, MARICEL GUARIN (DDS)
Entity Type:Individual
Prefix:
First Name:MARICEL
Middle Name:GUARIN
Last Name:FORTIN
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 1:1415 E COLORADO ST
Mailing Address - Street 2:STE C
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1533
Mailing Address - Country:US
Mailing Address - Phone:818-545-7270
Mailing Address - Fax:
Practice Address - Street 1:1415 E COLORADO ST
Practice Address - Street 2:STE C
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1533
Practice Address - Country:US
Practice Address - Phone:818-545-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46812122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist