Provider Demographics
NPI:1568672343
Name:MAZZOLA, JOHN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:MAZZOLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 BLUE POINT AVENUE
Mailing Address - Street 2:
Mailing Address - City:BLUE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11715-1222
Mailing Address - Country:US
Mailing Address - Phone:631-363-7040
Mailing Address - Fax:631-363-7046
Practice Address - Street 1:193 BLUE POINT AVENUE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1222
Practice Address - Country:US
Practice Address - Phone:631-363-7040
Practice Address - Fax:631-363-7046
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0401031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice