Provider Demographics
NPI:1912261520
Name:DIEGUEZ-MARINO, BERTHA M (DMD,MPH)
Entity type:Individual
Prefix:DR
First Name:BERTHA
Middle Name:M
Last Name:DIEGUEZ-MARINO
Suffix:
Gender:F
Credentials:DMD,MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2072 CAHABA CREST DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-4417
Mailing Address - Country:US
Mailing Address - Phone:205-785-3179
Mailing Address - Fax:205-785-3257
Practice Address - Street 1:316 VALLEY RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:AL
Practice Address - Zip Code:35064-2222
Practice Address - Country:US
Practice Address - Phone:205-785-3179
Practice Address - Fax:205-785-3257
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL42241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics