Provider Demographics
NPI:1679627897
Name:FREDERICK J. MARRA, D.M.D. PLLC
Entity Type:Organization
Organization Name:FREDERICK J. MARRA, D.M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR.
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-237-0019
Mailing Address - Street 1:100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047-4404
Mailing Address - Country:US
Mailing Address - Phone:518-237-0019
Mailing Address - Fax:518-237-5461
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:COHOES
Practice Address - State:NY
Practice Address - Zip Code:12047-4404
Practice Address - Country:US
Practice Address - Phone:518-237-0019
Practice Address - Fax:518-237-5461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035737122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty