Provider Demographics
NPI:1265168769
Name:ORSO, MARIESSA LORAE (RDH)
Entity type:Individual
Prefix:
First Name:MARIESSA
Middle Name:LORAE
Last Name:ORSO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:MARIESSA
Other - Middle Name:LORAE
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 CALIFORNIA ST
Mailing Address - Street 2:PO BOX 577
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918
Mailing Address - Country:US
Mailing Address - Phone:618-519-9200
Mailing Address - Fax:
Practice Address - Street 1:402 S LEWIS LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3547
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.011952124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist