Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 107059 | CA |
NPI | 1003436965 |
---|---|
Provider Name | Marina Ann Mikael |
First Address | Weston, MA 02493-2608 |
Second Address | Weston, MA 02493-2608 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2020 |
Last Update Date | 01/12/2021 |