Provider Demographics
NPI:1508077397
Name:MARCANTONIO, MIKE H (DMD)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:H
Last Name:MARCANTONIO
Suffix:
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 1:4310 HIDDEN LAKES DR E
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4180
Mailing Address - Country:US
Mailing Address - Phone:850-420-6750
Mailing Address - Fax:
Practice Address - Street 1:4272 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-2808
Practice Address - Country:US
Practice Address - Phone:850-626-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN167761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1941867OtherUNITED CONCORDIA