Healthcare Provider Details

I. General information

NPI: 1821121112
Provider Name (Legal Business Name): MARENDA D DENT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 SHOAL CREEK BLVD STE 130W
AUSTIN TX
78757-1040
US

IV. Provider business mailing address

PO BOX 1239
TROY MI
48099-1239
US

V. Phone/Fax

Practice location:
  • Phone: 512-407-8880
  • Fax: 512-407-8681
Mailing address:
  • Phone: 888-873-9595
  • Fax: 877-473-8164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2006-01913
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM7795
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: