Provider Demographics
NPI:1821621095
Name:BUTTRICK, MAYRA GABRIELA
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:GABRIELA
Last Name:BUTTRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:GABRIELA
Other - Last Name:GONZALEZ GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:750 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-3817
Mailing Address - Country:US
Mailing Address - Phone:305-694-5400
Mailing Address - Fax:
Practice Address - Street 1:750 E 25TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3817
Practice Address - Country:US
Practice Address - Phone:305-694-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM2151390200000X
390200000X
FLDN26831122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program