Provider Demographics
NPI:1659787042
Name:SKROMBOLAS, MARINA (DDS)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:SKROMBOLAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-1571
Mailing Address - Country:US
Mailing Address - Phone:585-228-1195
Mailing Address - Fax:585-786-0053
Practice Address - Street 1:81 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-1571
Practice Address - Country:US
Practice Address - Phone:585-228-1195
Practice Address - Fax:585-786-0053
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0579631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04238991Medicaid