Provider Demographics
NPI:1508023235
Name:MARYSOL B. REALON DDS A PROF. DENTAL CORP
Entity Type:Organization
Organization Name:MARYSOL B. REALON DDS A PROF. DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYSOL
Authorized Official - Middle Name:B
Authorized Official - Last Name:REALON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-629-8573
Mailing Address - Street 1:259 E. LOUISE AVE
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330
Mailing Address - Country:US
Mailing Address - Phone:209-629-8573
Mailing Address - Fax:209-629-8574
Practice Address - Street 1:259 E. LOUISE AVE
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330
Practice Address - Country:US
Practice Address - Phone:209-629-8573
Practice Address - Fax:209-629-8574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53855122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty