Provider Demographics
NPI:1538327051
Name:MOKRUSHIN, MARINA V (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARINA
Middle Name:V
Last Name:MOKRUSHIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9480 MADISON AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-4996
Mailing Address - Country:US
Mailing Address - Phone:916-603-4440
Mailing Address - Fax:
Practice Address - Street 1:9480 MADISON AVE STE 6
Practice Address - Street 2:
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-4996
Practice Address - Country:US
Practice Address - Phone:916-603-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54893122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist