Provider Demographics
NPI:1760802334
Name:AWAD, MARINA
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:AWAD
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 1:2465 IRON POINT RD
Mailing Address - Street 2:STE 120
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-8754
Mailing Address - Country:US
Mailing Address - Phone:916-984-9600
Mailing Address - Fax:
Practice Address - Street 1:2465 IRON POINT RD
Practice Address - Street 2:STE 120
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-8754
Practice Address - Country:US
Practice Address - Phone:916-984-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA649971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program