Healthcare Provider Details

I. General information

NPI: 1134421985
Provider Name (Legal Business Name): CHRISTINE MARCELO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 E GREEN ST UNIT 131
PASADENA CA
91101-5427
US

IV. Provider business mailing address

840 E GREEN ST UNIT 131
PASADENA CA
91101-5427
US

V. Phone/Fax

Practice location:
  • Phone: 818-642-5272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number59420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: