Provider Demographics
NPI:1265714067
Name:TULLY, MARC J (DMD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:J
Last Name:TULLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2162
Mailing Address - Country:US
Mailing Address - Phone:310-379-6798
Mailing Address - Fax:310-379-6501
Practice Address - Street 1:901 N PACIFIC COAST HWY STE 200B
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-7702
Practice Address - Country:US
Practice Address - Phone:310-379-6798
Practice Address - Fax:310-379-6501
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02474000122300000X
CA64401122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist