Provider Demographics
NPI:1265498950
Name:MARINO, NICHOLAS L (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:L
Last Name:MARINO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 NORTH CREEK DR
Mailing Address - Street 2:PO BOX 489
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028
Mailing Address - Country:US
Mailing Address - Phone:636-937-9445
Mailing Address - Fax:636-931-7680
Practice Address - Street 1:660 NORTH CREEK DR
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028
Practice Address - Country:US
Practice Address - Phone:636-937-9445
Practice Address - Fax:636-931-7680
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01585122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist