Provider Demographics
NPI:1740897487
Name:MICHAEL, MARENA G F
Entity type:Individual
Prefix:DR
First Name:MARENA
Middle Name:G F
Last Name:MICHAEL
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 1:1705 GARVEY AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-4257
Mailing Address - Country:US
Mailing Address - Phone:909-660-9684
Mailing Address - Fax:
Practice Address - Street 1:2216 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2944
Practice Address - Country:US
Practice Address - Phone:909-392-3899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist