Provider Demographics
NPI:1336492024
Name:MAHACEK, DONNA (RDH)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:
Last Name:MAHACEK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2764 SEBASTIAN CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2896
Mailing Address - Country:US
Mailing Address - Phone:904-655-4259
Mailing Address - Fax:
Practice Address - Street 1:2764 SEBASTIAN CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2896
Practice Address - Country:US
Practice Address - Phone:904-655-4259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21909124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist