Provider Demographics
NPI:1417009150
Name:MAGNACCA, JOHN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:MAGNACCA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:900 NW 13TH STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486
Mailing Address - Country:US
Mailing Address - Phone:561-391-6234
Mailing Address - Fax:561-391-0743
Practice Address - Street 1:900 NW 13TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2335
Practice Address - Country:US
Practice Address - Phone:561-391-6234
Practice Address - Fax:561-391-0743
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL062211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55213Medicare UPIN