Provider Demographics
NPI:1689859589
Name:JOHN MASCARO D M D M D AND CARL CHOI D D S M D INC
Entity Type:Organization
Organization Name:JOHN MASCARO D M D M D AND CARL CHOI D D S M D INC
Other - Org Name:GREAT LAKES JAW AND IMPLANT SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASCARO
Authorized Official - Suffix:
Authorized Official - Credentials:D M D M D
Authorized Official - Phone:440-946-2247
Mailing Address - Street 1:4230 STATE ROUTE 306 STE 350
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9213
Mailing Address - Country:US
Mailing Address - Phone:440-946-2247
Mailing Address - Fax:440-946-3530
Practice Address - Street 1:4230 STATE ROUTE 306 STE 350
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9213
Practice Address - Country:US
Practice Address - Phone:440-946-2247
Practice Address - Fax:440-946-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9300581Medicare PIN