Provider Demographics
NPI:1720122351
Name:AFURONG, MARIAN B (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIAN
Middle Name:B
Last Name:AFURONG
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 1:2440 S HACIENDA BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-4775
Mailing Address - Country:US
Mailing Address - Phone:626-968-2020
Mailing Address - Fax:626-968-7021
Practice Address - Street 1:2440 S HACIENDA BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-4775
Practice Address - Country:US
Practice Address - Phone:626-968-2020
Practice Address - Fax:626-968-7021
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA231020OtherMEDI-CAL PROVIDER NUMBER