Provider Demographics
NPI:1790035145
Name:ANTHONY MARINO D.D.S., M.S. PROFESSIONAL CORORATION
Entity type:Organization
Organization Name:ANTHONY MARINO D.D.S., M.S. PROFESSIONAL CORORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RDA / FRONT OFFICE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:COREN
Authorized Official - Last Name:RE
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:707-448-6271
Mailing Address - Street 1:290 ALAMO DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-4245
Mailing Address - Country:US
Mailing Address - Phone:707-448-6271
Mailing Address - Fax:707-448-4742
Practice Address - Street 1:1010 EMPIRE STREET
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5707
Practice Address - Country:US
Practice Address - Phone:707-448-6271
Practice Address - Fax:707-448-4742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA345211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty