Provider Demographics
NPI:1114805413
Name:MARIVIC C AGONCILLO DDS INC
Entity type:Organization
Organization Name:MARIVIC C AGONCILLO DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIVIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:AGONCILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-731-0625
Mailing Address - Street 1:343 GELLERT BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2620
Mailing Address - Country:US
Mailing Address - Phone:650-731-0625
Mailing Address - Fax:650-997-3542
Practice Address - Street 1:343 GELLERT BLVD STE G
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2620
Practice Address - Country:US
Practice Address - Phone:650-731-0625
Practice Address - Fax:650-997-3542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental