Healthcare Provider Details

I. General information

NPI: 1033292487
Provider Name (Legal Business Name): MICHELLE MARCONNETTE, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2006
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3936 PHELAN RD STE A4
PHELAN CA
92371-4142
US

IV. Provider business mailing address

3936 PHELAN RD STE A4
PHELAN CA
92371-4142
US

V. Phone/Fax

Practice location:
  • Phone: 760-868-4600
  • Fax: 760-868-8449
Mailing address:
  • Phone: 760-868-4600
  • Fax: 760-868-8449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43464
License Number StateCA

VIII. Authorized Official

Name: MRS. MICHELLE S. MARCONNETTE-BENDER
Title or Position: OWNER
Credential: D.D.S.
Phone: 760-868-4600