Provider Demographics
NPI:1639837651
Name:MARINO, NICOLIN M
Entity Type:Individual
Prefix:DR
First Name:NICOLIN
Middle Name:M
Last Name:MARINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 DRAKE LN
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-1228
Mailing Address - Country:US
Mailing Address - Phone:516-551-8756
Mailing Address - Fax:
Practice Address - Street 1:1025 NORTHERN BLVD STE 306
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1506
Practice Address - Country:US
Practice Address - Phone:516-627-4151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03522091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics