Provider Demographics
NPI:1326489097
Name:DURAZO, MARIO M (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:M
Last Name:DURAZO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 433996
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92143-3996
Mailing Address - Country:US
Mailing Address - Phone:619-781-9961
Mailing Address - Fax:
Practice Address - Street 1:482 W SAN YSIDRO BLVD
Practice Address - Street 2:SUITE 1944
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-2444
Practice Address - Country:US
Practice Address - Phone:619-781-9961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1266129122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist