Provider Demographics
NPI:1215104294
Name:JURASIC, MARIANNE (DMD)
Entity type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:
Last Name:JURASIC
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MIRJANA
Other - Middle Name:MARIANNE
Other - Last Name:JURASIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:100 E NEWTON ST
Mailing Address - Street 2:G 619
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E NEWTON ST
Practice Address - Street 2:G 619
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-638-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA187541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice