Provider Demographics
NPI:1316389232
Name:PERDOMO, MAURO D JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAURO
Middle Name:D
Last Name:PERDOMO
Suffix:JR
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 1:111 LAWRENCE ST
Mailing Address - Street 2:APT. 5E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 LAWRENCE ST
Practice Address - Street 2:APT. 5E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3860
Practice Address - Country:US
Practice Address - Phone:201-927-3607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056679-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist