Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DN15711 | FL |
NPI | 1003941022 |
---|---|
Provider Name | Maria Mazzucco |
First Address | Orlando, FL 32886-2851 |
Second Address | Deerfield Bch, FL 33441-6222 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2007 |
Last Update Date | 14/09/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
075557500 | (05) | FL |
83355 | BCBS (01) | FL |
V02237 | (02) | FL |