Provider Demographics
NPI:1831302389
Name:REALON, MARYSOL B (DDS)
Entity type:Individual
Prefix:
First Name:MARYSOL
Middle Name:B
Last Name:REALON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 E. LOUISE AVE
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-9752
Mailing Address - Country:US
Mailing Address - Phone:209-629-8573
Mailing Address - Fax:
Practice Address - Street 1:259 LOUISE AVE
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-8631
Practice Address - Country:US
Practice Address - Phone:209-629-8573
Practice Address - Fax:209-629-5874
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53855122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist