Provider Demographics
NPI:1528596400
Name:COPELAND, MARICON DIZON (DMD)
Entity Type:Individual
Prefix:
First Name:MARICON
Middle Name:DIZON
Last Name:COPELAND
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MARICON
Other - Middle Name:DIZON
Other - Last Name:PANGILINAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5640 N BARRASCA AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-1328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7645 N ORACLE RD STE 120
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85704-6569
Practice Address - Country:US
Practice Address - Phone:520-318-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZD009816122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program