Provider Demographics
NPI:1619989654
Name:MASCARO, JOHN ROBERT (DMD MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:MASCARO
Suffix:
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 STATE ROUTE 306
Mailing Address - Street 2:SUITE 350
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094
Mailing Address - Country:US
Mailing Address - Phone:440-946-2247
Mailing Address - Fax:440-946-3530
Practice Address - Street 1:4230 STATE ROUTE 306
Practice Address - Street 2:SUITE 350
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-946-2247
Practice Address - Fax:440-946-3530
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300199071223S0112X
OH350662801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0863531Medicare ID - Type Unspecified
F90052Medicare UPIN
0863531Medicare PIN