Provider Demographics
NPI:1649380932
Name:MARCHAN, SELENA LOTERINA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SELENA
Middle Name:LOTERINA
Last Name:MARCHAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2467 BLACKBEARD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1139
Mailing Address - Country:US
Mailing Address - Phone:904-221-5678
Mailing Address - Fax:904-220-5678
Practice Address - Street 1:13475 ATLANTIC BLVD
Practice Address - Street 2:STE 36
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3291
Practice Address - Country:US
Practice Address - Phone:904-221-5678
Practice Address - Fax:904-220-5678
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN134591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice