=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912057019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERNEST MICHAEL MARINO DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 74 ALLDS ST STE 4
-----------------------------------------------------
City | NASHUA
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03060-4757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-883-1544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 614 NASHUA ST #65
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03055-4943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | NH1146
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------