Provider Demographics
NPI:1033292487
Name:MICHELLE MARCONNETTE, D.D.S., INC.
Entity Type:Organization
Organization Name:MICHELLE MARCONNETTE, D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MARCONNETTE-BENDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-868-4600
Mailing Address - Street 1:3936 PHELAN RD STE A4
Mailing Address - Street 2:
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92371-4142
Mailing Address - Country:US
Mailing Address - Phone:760-868-4600
Mailing Address - Fax:760-868-8449
Practice Address - Street 1:3936 PHELAN RD STE A4
Practice Address - Street 2:
Practice Address - City:PHELAN
Practice Address - State:CA
Practice Address - Zip Code:92371-4142
Practice Address - Country:US
Practice Address - Phone:760-868-4600
Practice Address - Fax:760-868-8449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA434641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty