Provider Demographics
NPI:1295268936
Name:OBIEDZINSKI, MARISSA (DMD)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:OBIEDZINSKI
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 1:111 E 57TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2009
Mailing Address - Country:US
Mailing Address - Phone:917-512-8302
Mailing Address - Fax:732-631-8525
Practice Address - Street 1:111 E 57TH ST STE 204
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2009
Practice Address - Country:US
Practice Address - Phone:917-512-8302
Practice Address - Fax:732-631-8525
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061586-01122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program