Healthcare Provider Details

I. General information

NPI: 1295936086
Provider Name (Legal Business Name): GEORGE A MARYNIUK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 HARVARD ST SUITE 302
BROOKLINE MA
02446-5071
US

IV. Provider business mailing address

209 HARVARD ST SUITE 302
BROOKLINE MA
02446-5071
US

V. Phone/Fax

Practice location:
  • Phone: 617-566-4108
  • Fax: 617-566-4142
Mailing address:
  • Phone: 617-566-4108
  • Fax: 617-566-4142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number14004
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: