Provider Demographics
NPI:1346801123
Name:DANIEL, MARISOLY
Entity Type:Individual
Prefix:
First Name:MARISOLY
Middle Name:
Last Name:DANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2463 W 72ND ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6509
Mailing Address - Country:US
Mailing Address - Phone:305-804-3011
Mailing Address - Fax:
Practice Address - Street 1:8060 NW 155TH ST STE 200
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-5883
Practice Address - Country:US
Practice Address - Phone:305-804-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist