Healthcare Provider Details

I. General information

NPI: 1528097516
Provider Name (Legal Business Name): VANESSA COELHO MARINHO D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17250 N 43RD AVE SUITE 5
GLENDALE AZ
85308-4035
US

IV. Provider business mailing address

17250 N 43RD AVE SUITE 5
GLENDALE AZ
85308-4035
US

V. Phone/Fax

Practice location:
  • Phone: 602-978-8433
  • Fax:
Mailing address:
  • Phone: 602-978-8433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5823
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: