Provider Demographics
NPI:1194217166
Name:ENDIAKOV, MARIO (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:ENDIAKOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MAGNOLIA CIR
Mailing Address - Street 2:
Mailing Address - City:TYNDALL AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32403-5604
Mailing Address - Country:US
Mailing Address - Phone:850-283-7444
Mailing Address - Fax:
Practice Address - Street 1:340 MAGNOLIA CIR
Practice Address - Street 2:
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403-5604
Practice Address - Country:US
Practice Address - Phone:850-283-7128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL019031843122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program