Provider Demographics
NPI:1215076930
Name:WELBURN, MARISA J (DDS)
Entity type:Individual
Prefix:DR
First Name:MARISA
Middle Name:J
Last Name:WELBURN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 S. HEALTH PKWY
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-9362
Mailing Address - Country:US
Mailing Address - Phone:269-279-7876
Mailing Address - Fax:269-279-5823
Practice Address - Street 1:717 S. HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-9362
Practice Address - Country:US
Practice Address - Phone:269-279-7876
Practice Address - Fax:269-279-5823
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010191471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice