Healthcare Provider Details

I. General information

NPI: 1225728512
Provider Name (Legal Business Name): MARINA REZKALLA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S TOWNLINE RD
WAUTOMA WI
54982-6922
US

IV. Provider business mailing address

400 S TOWNLINE RD
WAUTOMA WI
54982-6922
US

V. Phone/Fax

Practice location:
  • Phone: 224-535-0855
  • Fax:
Mailing address:
  • Phone: 224-535-0855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6001829-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: