Provider Demographics
NPI:1841579257
Name:MARIANNA ZADOV, P.A
Entity Type:Organization
Organization Name:MARIANNA ZADOV, P.A
Other - Org Name:POLO DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIZGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-241-7656
Mailing Address - Street 1:1905 CLINT MOORE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2660
Mailing Address - Country:US
Mailing Address - Phone:561-241-7656
Mailing Address - Fax:
Practice Address - Street 1:5030 CHAMPION BLVD STE G4
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-2478
Practice Address - Country:US
Practice Address - Phone:561-241-7656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN164481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1104903301Medicaid