Provider Demographics
NPI:1225728512
Name:REZKALLA, MARINA (DMD)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:REZKALLA
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 1:400 S TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-6922
Mailing Address - Country:US
Mailing Address - Phone:224-535-0855
Mailing Address - Fax:
Practice Address - Street 1:400 S TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-6922
Practice Address - Country:US
Practice Address - Phone:224-535-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X, 390200000X
WI6001829-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program