Provider Demographics
NPI:1306415179
Name:PONTRELLI, MARISA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:
Last Name:PONTRELLI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 N RD 214
Mailing Address - Street 2:
Mailing Address - City:LINDSAY
Mailing Address - State:CA
Mailing Address - Zip Code:93247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:709 NORTH RD 214
Practice Address - Street 2:
Practice Address - City:LINDSAY
Practice Address - State:CA
Practice Address - Zip Code:93247
Practice Address - Country:US
Practice Address - Phone:559-562-5171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10008746122300000X
CA1065751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist