Provider Demographics
NPI:1790138774
Name:GRUZMARK, MITCHELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:GRUZMARK
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 1:7225 PORT MARNOCK DR
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-2061
Mailing Address - Country:US
Mailing Address - Phone:847-757-8033
Mailing Address - Fax:
Practice Address - Street 1:4410 W 16TH AVE STE 52
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7193
Practice Address - Country:US
Practice Address - Phone:305-825-9899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030822122300000X
FLDN245661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114189300Medicaid