=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386914125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARINO J. ALEA IGLESIAS, DDS, P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2012
-----------------------------------------------------
Last Update Date | 01/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2425 NAGLEE RD
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95304-7324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-833-7392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2425 NAGLEE RD
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95304-7324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-833-7392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OWNER
-----------------------------------------------------
Name | MARINO J ALEA IGLESIAS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 209-833-7392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 60649
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------