Provider Demographics
NPI:1518085828
Name:RUBIO ELLIS, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:RUBIO ELLIS
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 1:822 EAST UNION HILLS DR
Mailing Address - Street 2:STE D6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024
Mailing Address - Country:US
Mailing Address - Phone:623-582-6789
Mailing Address - Fax:623-780-3344
Practice Address - Street 1:822 EAST UNION HILLS DR
Practice Address - Street 2:STE D6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024
Practice Address - Country:US
Practice Address - Phone:623-582-6789
Practice Address - Fax:623-780-3344
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD48951223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics