Provider Demographics
NPI:1538206537
Name:DESRONVIL-LISSADE, MARCELLE (DMD)
Entity type:Individual
Prefix:
First Name:MARCELLE
Middle Name:
Last Name:DESRONVIL-LISSADE
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 1:2127 CRIGAN BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8352
Mailing Address - Country:US
Mailing Address - Phone:267-981-0360
Mailing Address - Fax:
Practice Address - Street 1:1111 S POLLOCK ST
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:NC
Practice Address - Zip Code:27576-2933
Practice Address - Country:US
Practice Address - Phone:919-965-2552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8716122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist