Healthcare Provider Details

I. General information

NPI: 1215166855
Provider Name (Legal Business Name): MARIVIC BAUTISTA PANOPIO RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 07/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 NW 119TH ST
NORTH MIAMI FL
33167-3231
US

IV. Provider business mailing address

1245 NW 119TH ST
NORTH MIAMI FL
33167-3231
US

V. Phone/Fax

Practice location:
  • Phone: 305-685-7863
  • Fax: 305-687-7603
Mailing address:
  • Phone: 305-685-7863
  • Fax: 305-687-7603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH18958
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: