Provider Demographics
NPI:1629640685
Name:SY-MARCIAL, CHANELLE RIANNA
Entity type:Individual
Prefix:DR
First Name:CHANELLE
Middle Name:RIANNA
Last Name:SY-MARCIAL
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 1:25212 MARGUERITE PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-2928
Mailing Address - Country:US
Mailing Address - Phone:310-561-4877
Mailing Address - Fax:
Practice Address - Street 1:25212 MARGUERITE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-2928
Practice Address - Country:US
Practice Address - Phone:310-561-4877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-10
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106423122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist