Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DN20307 | FL |
N | 204E00000X | Oral & Maxillofacial Surgeon | DN20307 | FL |
NPI | 1003175498 |
---|---|
Provider Name | Anthony Massaro |
First Address | Jacksonville, FL 32207-5205 |
Second Address | Jacksonville, FL 32209 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2012 |
Last Update Date | 28/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
712859 | (05) | FL |