Healthcare Provider Details

I. General information

NPI: 1508023235
Provider Name (Legal Business Name): MARYSOL B. REALON DDS A PROF. DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E. LOUISE AVE
LATHROP CA
95330
US

IV. Provider business mailing address

259 E. LOUISE AVE
LATHROP CA
95330
US

V. Phone/Fax

Practice location:
  • Phone: 209-629-8573
  • Fax: 209-629-8574
Mailing address:
  • Phone: 209-629-8573
  • Fax: 209-629-8574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number53855
License Number StateCA

VIII. Authorized Official

Name: MRS. MARYSOL B. REALON
Title or Position: DENTIST
Credential: DDS
Phone: 209-629-8573