Healthcare Provider Details

I. General information

NPI: 1629205174
Provider Name (Legal Business Name): MARC DENTICO-OLIN DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WASHINGTON ST STE 710
SAN DIEGO CA
92103-2231
US

IV. Provider business mailing address

501 WASHINGTON ST STE 710
SAN DIEGO CA
92103-2231
US

V. Phone/Fax

Practice location:
  • Phone: 619-295-6774
  • Fax: 619-295-6776
Mailing address:
  • Phone: 619-295-6774
  • Fax: 619-295-6776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA143794
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberOMS109
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberA143794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: