Healthcare Provider Details

I. General information

NPI: 1629328638
Provider Name (Legal Business Name): STEVEN P MARINKOVICH DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 TACOMA MALL BLVD SUITE E-104
TACOMA WA
98409-7018
US

IV. Provider business mailing address

5225 TACOMA MALL BLVD SUITE E-104
TACOMA WA
98409-7018
US

V. Phone/Fax

Practice location:
  • Phone: 253-474-3223
  • Fax: 253-473-6762
Mailing address:
  • Phone: 253-474-3223
  • Fax: 253-473-6762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberDE00004767
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: STEVEN P MARINKOVICH
Title or Position: OWNER/DOCTOR
Credential: DDS, ABDSM
Phone: 253-474-3223