Provider Demographics
NPI:1083022040
Name:MARRA, WILLIAM (DMD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:MARRA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4980 SW LANDING DR APT 302
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-5967
Mailing Address - Country:US
Mailing Address - Phone:412-855-1107
Mailing Address - Fax:
Practice Address - Street 1:2520 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1754
Practice Address - Country:US
Practice Address - Phone:503-233-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD100731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice