Provider Demographics
NPI:1477341865
Name:CARBONELL MENESES, MARICEL
Entity type:Individual
Prefix:
First Name:MARICEL
Middle Name:
Last Name:CARBONELL MENESES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 W BASELINE RD STE 170
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-3044
Mailing Address - Country:US
Mailing Address - Phone:602-825-8420
Mailing Address - Fax:
Practice Address - Street 1:3624 W BASELINE RD STE 170
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-3044
Practice Address - Country:US
Practice Address - Phone:602-825-8420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ143821122300000X
AZ20230419123217126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126800000XDental ProvidersDental Assistant
No122300000XDental ProvidersDentistGroup - Multi-Specialty