Provider Demographics
NPI:1275680944
Name:MARCELLO, STEVEN J (DDS)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:J
Last Name:MARCELLO
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 1:156 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-5216
Mailing Address - Country:US
Mailing Address - Phone:985-446-3754
Mailing Address - Fax:985-449-1582
Practice Address - Street 1:156 W MAIN ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5216
Practice Address - Country:US
Practice Address - Phone:985-446-3754
Practice Address - Fax:985-449-1582
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA35701223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174753321Medicaid
LA1275680944Medicaid