Provider Demographics
NPI:1295000339
Name:MARYAM BRAZDO, DMD, PA
Entity Type:Organization
Organization Name:MARYAM BRAZDO, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAZDO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-243-2030
Mailing Address - Street 1:1061 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1652
Mailing Address - Country:US
Mailing Address - Phone:321-724-1400
Mailing Address - Fax:
Practice Address - Street 1:1061 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1652
Practice Address - Country:US
Practice Address - Phone:321-724-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN183921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty