Provider Demographics
NPI:1114023108
Name:MARINER, ROBERT W
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:MARINER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2648 JAMACHA RD
Mailing Address - Street 2:SUITE 166
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-4346
Mailing Address - Country:US
Mailing Address - Phone:619-670-5571
Mailing Address - Fax:
Practice Address - Street 1:2648 JAMACHA RD
Practice Address - Street 2:SUITE 166
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-4346
Practice Address - Country:US
Practice Address - Phone:619-670-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist