Provider Demographics
NPI:1194870121
Name:MARIM-EBERHARDT, JOELY (DMD, MS)
Entity type:Individual
Prefix:
First Name:JOELY
Middle Name:
Last Name:MARIM-EBERHARDT
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:JOELY
Other - Middle Name:
Other - Last Name:MARIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:27550 STATE HIGHWAY 75 STE 104
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-3204
Mailing Address - Country:US
Mailing Address - Phone:205-274-2414
Mailing Address - Fax:
Practice Address - Street 1:27550 STATE HIGHWAY 75 STE 104
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-3204
Practice Address - Country:US
Practice Address - Phone:205-274-2414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL53431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009935682Medicaid