Provider Demographics
NPI:1063543494
Name:CHAVEZ, MARCO MELVIN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARCO
Middle Name:MELVIN
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 MISSION STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110
Mailing Address - Country:US
Mailing Address - Phone:415-821-0101
Mailing Address - Fax:415-821-4772
Practice Address - Street 1:2460 MISSION STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110
Practice Address - Country:US
Practice Address - Phone:415-821-0101
Practice Address - Fax:415-821-4772
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2843101OtherDENTI CAL