Provider Demographics
NPI:1619184165
Name:SCAMURRA, MICHAEL JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:SCAMURRA
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 1:18700 MAIN ST
Mailing Address - Street 2:STE 207
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1706
Mailing Address - Country:US
Mailing Address - Phone:714-841-0100
Mailing Address - Fax:714-841-0107
Practice Address - Street 1:18700 MAIN ST
Practice Address - Street 2:STE 207
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1706
Practice Address - Country:US
Practice Address - Phone:714-841-0100
Practice Address - Fax:714-841-0107
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051251122300000X
CA55501122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02617843Medicaid