Provider Demographics
NPI:1366574311
Name:AGONCILLO, MARIVIC A (DDS)
Entity type:Individual
Prefix:DR
First Name:MARIVIC
Middle Name:A
Last Name:AGONCILLO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARIVIC
Other - Middle Name:C
Other - Last Name:AGONCILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2480 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-2850
Mailing Address - Country:US
Mailing Address - Phone:650-216-8488
Mailing Address - Fax:650-216-7488
Practice Address - Street 1:343 GELLERT BLVD STE G
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2620
Practice Address - Country:US
Practice Address - Phone:650-731-0625
Practice Address - Fax:650-997-3542
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA433041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice