Healthcare Provider Details

I. General information

NPI: 1295268936
Provider Name (Legal Business Name): MARISSA OBIEDZINSKI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 57TH ST STE 204
NEW YORK NY
10022-2009
US

IV. Provider business mailing address

111 E 57TH ST STE 204
NEW YORK NY
10022-2009
US

V. Phone/Fax

Practice location:
  • Phone: 917-512-8302
  • Fax: 732-631-8525
Mailing address:
  • Phone: 917-512-8302
  • Fax: 732-631-8525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number061586-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: