Provider Demographics
NPI:1265830590
Name:SHUROVA, MARINA
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:SHUROVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23202 CYPRESS TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-8763
Mailing Address - Country:US
Mailing Address - Phone:347-247-7930
Mailing Address - Fax:
Practice Address - Street 1:17521 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4521
Practice Address - Country:US
Practice Address - Phone:813-908-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN210191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FS6141422OtherDEA