Provider Demographics
NPI:1992478036
Name:CHANIN, MARISA REAGAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MARISA
Middle Name:REAGAN
Last Name:CHANIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 SW 70TH TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-3126
Mailing Address - Country:US
Mailing Address - Phone:407-509-0187
Mailing Address - Fax:
Practice Address - Street 1:3301 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-7721
Practice Address - Country:US
Practice Address - Phone:407-509-0187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry