Provider Demographics
NPI:1407991706
Name:EAVES, MARILYN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:
Last Name:EAVES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARILYN
Other - Middle Name:
Other - Last Name:EAVES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:660 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1035
Mailing Address - Country:US
Mailing Address - Phone:315-536-3341
Mailing Address - Fax:315-536-7465
Practice Address - Street 1:660 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1035
Practice Address - Country:US
Practice Address - Phone:315-536-3341
Practice Address - Fax:315-536-7465
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0376381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00781291Medicaid