Provider Demographics
NPI:1487111571
Name:CARVALHO, MARISSA MARGARET (DDS)
Entity type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:MARGARET
Last Name:CARVALHO
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 1:2780 SKYPARK DR STE 240
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5341
Mailing Address - Country:US
Mailing Address - Phone:424-458-6007
Mailing Address - Fax:424-337-8055
Practice Address - Street 1:2780 SKYPARK DR STE 240
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5341
Practice Address - Country:US
Practice Address - Phone:424-458-6007
Practice Address - Fax:424-337-8055
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1059221223P0221X
MDLL8521223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid