Provider Demographics
NPI:1144824590
Name:LEYVA FERNANDEZ, MARILYN (RDH)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:
Last Name:LEYVA FERNANDEZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 BLANDING BLVD STE 6B
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5065
Mailing Address - Country:US
Mailing Address - Phone:904-276-5950
Mailing Address - Fax:904-276-5359
Practice Address - Street 1:410 BLANDING BLVD STE 6B
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5065
Practice Address - Country:US
Practice Address - Phone:904-276-5950
Practice Address - Fax:904-276-5359
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH24841124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDH24841OtherLICENSE NUMBER