Provider Demographics
NPI:1487085668
Name:MARINO, ANELISSE (DMD)
Entity type:Individual
Prefix:DR
First Name:ANELISSE
Middle Name:
Last Name:MARINO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 NW 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33322-2528
Mailing Address - Country:US
Mailing Address - Phone:813-833-9597
Mailing Address - Fax:
Practice Address - Street 1:1209 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1640
Practice Address - Country:US
Practice Address - Phone:954-763-3358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20192122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015087600Medicaid