Basic Information
| Provider Information | |||||||||
| NPI: | 1528596400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COPELAND | ||||||||
| FirstName: | MARICON | ||||||||
| MiddleName: | DIZON | ||||||||
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| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PANGILINAN | ||||||||
| OtherFirstName: | MARICON | ||||||||
| OtherMiddleName: | DIZON | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5640 N BARRASCA AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857501328 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7645 N ORACLE RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | ORO VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857046569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203184455 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2017 | ||||||||
| LastUpdateDate: | 07/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 122300000X | D009816 | AZ | Y | Dental Providers | Dentist |
No ID Information.