Provider Demographics
NPI:1336652858
Name:MARINO FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:MARINO FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANELISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARINO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-833-9597
Mailing Address - Street 1:2401 NW 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33322-2528
Mailing Address - Country:US
Mailing Address - Phone:954-386-7500
Mailing Address - Fax:954-386-7777
Practice Address - Street 1:4506 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33351-5740
Practice Address - Country:US
Practice Address - Phone:954-386-7500
Practice Address - Fax:954-386-7777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20192261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental