Provider Demographics
NPI:1841572963
Name:DE SOUSA, MARVINA E (DMD)
Entity Type:Individual
Prefix:
First Name:MARVINA
Middle Name:E
Last Name:DE SOUSA
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 1:7060 NW 177TH ST APT 210
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33015-6254
Mailing Address - Country:US
Mailing Address - Phone:305-333-7927
Mailing Address - Fax:
Practice Address - Street 1:10271 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-6008
Practice Address - Country:US
Practice Address - Phone:954-447-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL194651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice