Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D010254 | AZ |
NPI | 1003374919 |
---|---|
Provider Name | Dr. Marina Ambridge |
First Address | Peoria, AZ 85383-1504 |
Second Address | Peoria, AZ 85383-1504 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/03/2019 |
Last Update Date | 10/03/2019 |