Provider Demographics
NPI:1093111668
Name:MARINA DENTAL
Entity Type:Organization
Organization Name:MARINA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:650-349-0111
Mailing Address - Street 1:2996 S NORFOLK ST STE E
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2076
Mailing Address - Country:US
Mailing Address - Phone:650-349-0111
Mailing Address - Fax:650-349-0133
Practice Address - Street 1:2996 S NORFOLK ST STE E
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2076
Practice Address - Country:US
Practice Address - Phone:650-349-0111
Practice Address - Fax:650-349-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA037127122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty