Provider Demographics
NPI:1164563367
Name:DONAHUE, MARIETTA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIETTA
Middle Name:
Last Name:DONAHUE
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 1:10 DICKANS LANE
Mailing Address - Street 2:
Mailing Address - City:MT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054
Mailing Address - Country:US
Mailing Address - Phone:856-727-1370
Mailing Address - Fax:
Practice Address - Street 1:21 NO BURLINGTON RD
Practice Address - Street 2:SOUTHWOOD STATE PRISON ALLCARE
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302
Practice Address - Country:US
Practice Address - Phone:856-459-7206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ220101238000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist