Provider Demographics
NPI:1558565796
Name:MAKARYUS, FADDY A (DMD)
Entity Type:Individual
Prefix:DR
First Name:FADDY
Middle Name:A
Last Name:MAKARYUS
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 1:17531 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4521
Mailing Address - Country:US
Mailing Address - Phone:813-444-5060
Mailing Address - Fax:
Practice Address - Street 1:17531 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4521
Practice Address - Country:US
Practice Address - Phone:813-444-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 189491223G0001X
NJ22DI023336001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice