Healthcare Provider Details

I. General information

NPI: 1730203712
Provider Name (Legal Business Name): MARLICE ARCANGEL PATAM D.D.S., M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 MONTROSE AVE
SOUTH PASADENA CA
91030-3435
US

IV. Provider business mailing address

1115 MONTROSE AVE
SOUTH PASADENA CA
91030-3435
US

V. Phone/Fax

Practice location:
  • Phone: 626-394-4946
  • Fax: 626-296-2779
Mailing address:
  • Phone: 626-394-4946
  • Fax: 626-296-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number42757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: