Provider Demographics
NPI:1750650859
Name:FANELLI, MARISSA ANNE (RDH)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:ANNE
Last Name:FANELLI
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 EDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2662
Mailing Address - Country:US
Mailing Address - Phone:201-562-8844
Mailing Address - Fax:
Practice Address - Street 1:741 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-4309
Practice Address - Country:US
Practice Address - Phone:973-483-1300
Practice Address - Fax:973-483-3787
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22HI00901200124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22HI00901200OtherRDH LICENSE NUMBER