Provider Demographics
NPI:1659464253
Name:IRAHETA, MARIO E (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:E
Last Name:IRAHETA
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 1:343 IVES DAIRY RD.
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179
Mailing Address - Country:US
Mailing Address - Phone:786-229-7011
Mailing Address - Fax:
Practice Address - Street 1:1246 W. 68 ST.
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014
Practice Address - Country:US
Practice Address - Phone:305-556-6100
Practice Address - Fax:305-556-4799
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16637122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist