Provider Demographics
NPI:1578211801
Name:MAROON, BRANDON KIAN GINO (DDS)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:KIAN GINO
Last Name:MAROON
Suffix:
Gender:M
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:PO BOX 3104
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA FE
Mailing Address - State:CA
Mailing Address - Zip Code:92067-3104
Mailing Address - Country:US
Mailing Address - Phone:858-386-6363
Mailing Address - Fax:
Practice Address - Street 1:310 3RD AVE STE C1B
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3954
Practice Address - Country:US
Practice Address - Phone:619-476-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107362122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist