Provider Demographics
NPI:1538694658
Name:MJM DENTISTRY
Entity Type:Organization
Organization Name:MJM DENTISTRY
Other - Org Name:FAMILY & COSMETIC DENTISTRY AT VISTA LAKES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:MORRA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-382-2282
Mailing Address - Street 1:6415 S CHICKASAW TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-8366
Mailing Address - Country:US
Mailing Address - Phone:407-382-2282
Mailing Address - Fax:407-382-2858
Practice Address - Street 1:6415 S CHICKASAW TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32829-8366
Practice Address - Country:US
Practice Address - Phone:407-382-2282
Practice Address - Fax:407-382-2858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN157141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty