Provider Demographics
NPI:1316581838
Name:SANTOS, MARIELY MARITZA (DENTIST)
Entity Type:Individual
Prefix:
First Name:MARIELY
Middle Name:MARITZA
Last Name:SANTOS
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11659 TROPICAL ISLE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-7281
Mailing Address - Country:US
Mailing Address - Phone:813-812-9144
Mailing Address - Fax:
Practice Address - Street 1:520 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5743
Practice Address - Country:US
Practice Address - Phone:813-812-9144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL244631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice