Provider Demographics
NPI:1851715924
Name:MARAIS, PHILIP GORDON
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:GORDON
Last Name:MARAIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3037
Mailing Address - Country:US
Mailing Address - Phone:626-585-9544
Mailing Address - Fax:626-449-4932
Practice Address - Street 1:1955 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-3037
Practice Address - Country:US
Practice Address - Phone:626-585-9544
Practice Address - Fax:626-449-4932
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27333122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist