Provider Demographics
NPI:1588171235
Name:MARISA PODESTO DDS, DENTAL CORPORATION
Entity type:Organization
Organization Name:MARISA PODESTO DDS, DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:LUDDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-267-2115
Mailing Address - Street 1:5050 BONITA RD
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1701
Mailing Address - Country:US
Mailing Address - Phone:619-267-2115
Mailing Address - Fax:619-354-4166
Practice Address - Street 1:5050 BONITA RD
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1701
Practice Address - Country:US
Practice Address - Phone:619-267-2115
Practice Address - Fax:619-354-4166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61894261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental