Healthcare Provider Details

I. General information

NPI: 1487941340
Provider Name (Legal Business Name): DR. MARISSA FAELDAN-SUAREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827 GREENFIELD AVE APT 105
LOS ANGELES CA
90025-4409
US

IV. Provider business mailing address

16018 AMAR RD
CITY OF INDUSTRY CA
91744-2203
US

V. Phone/Fax

Practice location:
  • Phone: 626-379-1110
  • Fax:
Mailing address:
  • Phone: 626-968-7525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number58944
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: