Provider Demographics
NPI:1841699394
Name:MARCONNETTE, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MARCONNETTE
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 1:3936 PHELAN RD
Mailing Address - Street 2:SUITE A4
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92371-4141
Mailing Address - Country:US
Mailing Address - Phone:760-868-4600
Mailing Address - Fax:760-868-8449
Practice Address - Street 1:3936 PHELAN RD
Practice Address - Street 2:SUITE A4
Practice Address - City:PHELAN
Practice Address - State:CA
Practice Address - Zip Code:92371-4141
Practice Address - Country:US
Practice Address - Phone:760-868-4600
Practice Address - Fax:760-868-8449
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA434641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice