Provider Demographics
NPI:1013264357
Name:FREIRE, MARCELO (DDS,PHD, DMED)
Entity type:Individual
Prefix:DR
First Name:MARCELO
Middle Name:
Last Name:FREIRE
Suffix:
Gender:M
Credentials:DDS,PHD, DMED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 CAPRICORN LN
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-3498
Mailing Address - Country:US
Mailing Address - Phone:858-200-1846
Mailing Address - Fax:
Practice Address - Street 1:4120 CAPRICORN LN
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-3498
Practice Address - Country:US
Practice Address - Phone:858-200-1846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1036041223P0300X
MADL11672390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program