Provider Demographics
NPI:1356838627
Name:TOLZIN, MARISA E
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:E
Last Name:TOLZIN
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 1:645 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-2719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:645 PLAZA DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-895-2298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-22
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0317221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019.031722OtherILLINOIS STATE LICENSE