Healthcare Provider Details

I. General information

NPI: 1215115217
Provider Name (Legal Business Name): MARNI L MENTIS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CORBETT ST SUITE 310
CLEARWATER FL
33756
US

IV. Provider business mailing address

109 13TH ST
BELLEAIR BEACH FL
33786-3303
US

V. Phone/Fax

Practice location:
  • Phone: 727-474-0205
  • Fax: 727-474-9179
Mailing address:
  • Phone: 727-365-8564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberOS 8521
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: