Provider Demographics
NPI:1164059192
Name:MARCUSSON, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:MARCUSSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10455 DOUBLE R BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-8905
Mailing Address - Country:US
Mailing Address - Phone:775-823-9797
Mailing Address - Fax:
Practice Address - Street 1:1308 LEOPARD ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-8905
Practice Address - Country:US
Practice Address - Phone:775-378-0592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126800000XDental ProvidersDental AssistantGroup - Single Specialty