Provider Demographics
NPI:1962088278
Name:KANAKOS, MARINA KRISTIN
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:KRISTIN
Last Name:KANAKOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BURTON LN STE 400
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-9441
Mailing Address - Country:US
Mailing Address - Phone:856-842-5400
Mailing Address - Fax:
Practice Address - Street 1:4 BURTON LN STE 400
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-9441
Practice Address - Country:US
Practice Address - Phone:856-842-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
13099390200000X
NJ22DI029616001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program