Provider Demographics
NPI:1346523974
Name:SORRENTINO, MARY ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:SORRENTINO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 COMMONS DR W
Mailing Address - Street 2:APT 1308
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-8484
Mailing Address - Country:US
Mailing Address - Phone:757-375-0766
Mailing Address - Fax:
Practice Address - Street 1:340 BOATNER ROAD
Practice Address - Street 2:BLGD. 2751
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542
Practice Address - Country:US
Practice Address - Phone:850-883-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413259122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist