Provider Demographics
NPI:1225170277
Name:PIMENTEL, MARIVIC
Entity Type:Individual
Prefix:DR
First Name:MARIVIC
Middle Name:
Last Name:PIMENTEL
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 1:7170 LAHINCH DR
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-3056
Mailing Address - Country:US
Mailing Address - Phone:209-634-0500
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:703 N. GOLDEN STATE BLVD.
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95380-3953
Practice Address - Country:US
Practice Address - Phone:209-634-0500
Practice Address - Fax:209-634-5038
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54864122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD54864Medicaid