Provider Demographics
NPI:1073988754
Name:MARIOLLE, MERCEDES C
Entity Type:Individual
Prefix:DR
First Name:MERCEDES
Middle Name:C
Last Name:MARIOLLE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MERCEDES
Other - Middle Name:CLAUDIA
Other - Last Name:MARIOLLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:27 MARGUERITE DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-2229
Mailing Address - Country:US
Mailing Address - Phone:510-450-0589
Mailing Address - Fax:
Practice Address - Street 1:1144 SONOMA AVE STE 108
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4812
Practice Address - Country:US
Practice Address - Phone:707-523-2399
Practice Address - Fax:707-523-1411
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65152122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist