Provider Demographics
NPI:1124331004
Name:PATT, MARISA ELIZABETH (DMD)
Entity type:Individual
Prefix:DR
First Name:MARISA
Middle Name:ELIZABETH
Last Name:PATT
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 1:595 MADISON AVE
Mailing Address - Street 2:STE 1208
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1907
Mailing Address - Country:US
Mailing Address - Phone:212-371-3311
Mailing Address - Fax:
Practice Address - Street 1:7490 CLUBHOUSE RD STE 101
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3720
Practice Address - Country:US
Practice Address - Phone:303-530-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002030891223P0700X
CT10233122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist