Provider Demographics
NPI:1548669807
Name:ORIGEL, MARISA
Entity type:Individual
Prefix:MS
First Name:MARISA
Middle Name:
Last Name:ORIGEL
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 1:1525 RUBIO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2742
Mailing Address - Country:US
Mailing Address - Phone:626-200-8461
Mailing Address - Fax:
Practice Address - Street 1:1811 S DEL MAR AVE
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-4154
Practice Address - Country:US
Practice Address - Phone:626-573-0573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63931122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist