Provider Demographics
NPI:1629205174
Name:DENTICO-OLIN, MARC (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:DENTICO-OLIN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 WASHINGTON ST STE 710
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2231
Mailing Address - Country:US
Mailing Address - Phone:619-295-6774
Mailing Address - Fax:619-295-6776
Practice Address - Street 1:501 WASHINGTON ST STE 710
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2231
Practice Address - Country:US
Practice Address - Phone:619-295-6774
Practice Address - Fax:619-295-6776
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA143794174400000X, 1223S0112X
CAOMS1091223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No174400000XOther Service ProvidersSpecialist