Provider Demographics
NPI:1558488353
Name:MARCONI, FRED I JR (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:I
Last Name:MARCONI
Suffix:JR
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19018 NE 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33180-2823
Mailing Address - Country:US
Mailing Address - Phone:305-932-4222
Mailing Address - Fax:305-935-4322
Practice Address - Street 1:19018 NE 29TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-2823
Practice Address - Country:US
Practice Address - Phone:305-932-4222
Practice Address - Fax:305-935-4322
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN132491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics