Provider Demographics
NPI:1497393896
Name:ABDULLAH, MARCO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:
Last Name:ABDULLAH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25590 PROSPECT AVE APT 44D
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3155
Mailing Address - Country:US
Mailing Address - Phone:415-352-9322
Mailing Address - Fax:
Practice Address - Street 1:15290 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8515
Practice Address - Country:US
Practice Address - Phone:760-493-3215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104591122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist