Provider Demographics
NPI:1619535614
Name:MARZOUK, MAXWELL F (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:F
Last Name:MARZOUK
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 1:3614 LAMPLIGHT DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1730
Mailing Address - Country:US
Mailing Address - Phone:703-424-6534
Mailing Address - Fax:
Practice Address - Street 1:4322 RAVENSWORTH RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-5630
Practice Address - Country:US
Practice Address - Phone:703-940-1359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0401416994122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program