Provider Demographics
NPI:1902853088
Name:BEVACQUA, MARILYN C
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:C
Last Name:BEVACQUA
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 1:40 BROOKLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-3802
Mailing Address - Country:US
Mailing Address - Phone:610-446-4225
Mailing Address - Fax:610-446-4271
Practice Address - Street 1:40 BROOKLINE BLVD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-3802
Practice Address - Country:US
Practice Address - Phone:610-446-4225
Practice Address - Fax:610-446-4271
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-024867-C122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist