Provider Demographics
NPI:1992855597
Name:CERVANTES, MARCO (DDS)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:CERVANTES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 N CENTRAL AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2808
Mailing Address - Country:US
Mailing Address - Phone:623-583-3001
Mailing Address - Fax:
Practice Address - Street 1:1705 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-6920
Practice Address - Country:US
Practice Address - Phone:877-809-5092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ57261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice