Provider Demographics
NPI:1912687245
Name:HAMILTON, MARISSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:
Last Name:HAMILTON
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 1:1727 BLUE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4099
Mailing Address - Country:US
Mailing Address - Phone:860-420-8866
Mailing Address - Fax:
Practice Address - Street 1:13927 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5486
Practice Address - Country:US
Practice Address - Phone:904-643-4075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28429122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist