Provider Demographics
NPI:1558759845
Name:LIDIA MARISELA MARCINKOWSKI DDS INC
Entity Type:Organization
Organization Name:LIDIA MARISELA MARCINKOWSKI DDS INC
Other - Org Name:MAGNOLIA DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LIDIA
Authorized Official - Middle Name:MARISELA
Authorized Official - Last Name:MARCINKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-278-8426
Mailing Address - Street 1:13100 MAGNOLIA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-5365
Mailing Address - Country:US
Mailing Address - Phone:951-278-8426
Mailing Address - Fax:951-278-8427
Practice Address - Street 1:13100 MAGNOLIA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-5365
Practice Address - Country:US
Practice Address - Phone:951-278-8426
Practice Address - Fax:951-278-8427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47125122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty