Healthcare Provider Details

I. General information

NPI: 1346445756
Provider Name (Legal Business Name): CLARISSA KATIA MARCOVICH D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 E 58TH ST SUITE 804
NEW YORK NY
10022-1236
US

IV. Provider business mailing address

219 TOM HUNTER RD
FORT LEE NJ
07024-5301
US

V. Phone/Fax

Practice location:
  • Phone: 212-753-2676
  • Fax: 212-753-2676
Mailing address:
  • Phone: 201-482-4017
  • Fax: 201-461-1524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number044655
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: