Provider Demographics
NPI:1326184508
Name:CHARLES MARVIN, DDS, P.C.
Entity type:Organization
Organization Name:CHARLES MARVIN, DDS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-354-4600
Mailing Address - Street 1:978 ROUTE 45
Mailing Address - Street 2:NORTHSIDE PLAZA, SUITE 207
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3521
Mailing Address - Country:US
Mailing Address - Phone:845-354-4600
Mailing Address - Fax:845-354-4653
Practice Address - Street 1:978 ROUTE 45
Practice Address - Street 2:NORTHSIDE PLAZA, SUITE 207
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3521
Practice Address - Country:US
Practice Address - Phone:845-354-4600
Practice Address - Fax:845-354-4653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048411-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02 042 244Medicaid