Healthcare Provider Details

I. General information

NPI: 1578751640
Provider Name (Legal Business Name): MARINO EPIFANIO GUZMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2007
Last Update Date: 10/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 AUDUBON AVE FL 2
NEW YORK NY
10033-4213
US

IV. Provider business mailing address

311 AUDUBON AVE FL 2
NEW YORK NY
10033-4213
US

V. Phone/Fax

Practice location:
  • Phone: 212-795-3486
  • Fax: 212-543-3230
Mailing address:
  • Phone: 212-795-3486
  • Fax: 212-543-3230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number046812
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: