=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598371718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RI MAROON DENTAL GROUP PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2020
-----------------------------------------------------
Last Update Date | 09/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1339 THIRD AVE
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91911-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-426-2040
-----------------------------------------------------
Fax | 619-863-0251
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1339 THIRD AVE
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91911-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-426-2040
-----------------------------------------------------
Fax | 619-863-0251
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | DR. ROBERT EDWARD MAROON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 619-947-0394
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------