Provider Demographics
NPI:1386266476
Name:DURAN, MARCOS ANTONIO SR (RDA92927)
Entity type:Individual
Prefix:MR
First Name:MARCOS
Middle Name:ANTONIO
Last Name:DURAN
Suffix:SR
Gender:M
Credentials:RDA92927
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6728 VINELAND AVE APT E
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-2053
Mailing Address - Country:US
Mailing Address - Phone:818-799-4901
Mailing Address - Fax:
Practice Address - Street 1:15350 NORDHOFF ST UNIT A
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-2234
Practice Address - Country:US
Practice Address - Phone:818-724-8416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA92927126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant