MEDICARE: BRIAN MATTHEW MARINO D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	22D102208900	NJ

General Provider Information

NPI Number	:	1366507022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN MATTHEW MARINO D.M.D

Provider Business Mailing Address
First Line	:	567 NEWARK POMPTON TPKE
Second Line	:
City	:	POMPTON PLAINS
State	:	NJ
Zip	:	07444-1737
Country	:	US
Telephone Number	:	973-831-0444
Fax Number	:	973-831-7770

Provider Business Practice Location Address
First Line	:	567 NEWARK POMPTON TPKE
Second Line	:
City	:	POMPTON PLAINS
State	:	NJ
Zip	:	07444-1737
Country	:	US
Telephone Number	:	973-831-0444
Fax Number	:	973-831-7770

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2006
Last Update Date	:	09/14/2007

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