Provider Demographics
NPI:1114698156
Name:CODY, MARISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:
Last Name:CODY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8215 GREENWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3686
Mailing Address - Country:US
Mailing Address - Phone:608-827-6453
Mailing Address - Fax:
Practice Address - Street 1:8215 GREENWAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3686
Practice Address - Country:US
Practice Address - Phone:608-827-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10027081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice