Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 30-024392 | CA |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 6973 | LA |
N | 204E00000X | Oral & Maxillofacial Surgeon | 104868 | CA |
N | 204E00000X | Oral & Maxillofacial Surgeon | 30-024392 | OH |
N | 204E00000X | Oral & Maxillofacial Surgeon | 6973 | LA |
Y | 204E00000X | Oral & Maxillofacial Surgeon | A169364 | CA |
NPI | 1033539606 |
---|---|
Provider Name | Andrei Marechek |
First Address | Los Angeles, CA 90012-3930 |
Second Address | Baton Rouge, LA 70808-2293 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/04/2014 |
Last Update Date | 17/04/2021 |