Provider Demographics
NPI:1922670561
Name:MACEDO, LARISA IGOREVNA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARISA
Middle Name:IGOREVNA
Last Name:MACEDO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LARISA
Other - Middle Name:IGOREVNA
Other - Last Name:MIRONOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2411 FRYER PT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-2722
Mailing Address - Country:US
Mailing Address - Phone:312-826-9218
Mailing Address - Fax:
Practice Address - Street 1:26831 S TAMIAMI TRL UNIT 48
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7828
Practice Address - Country:US
Practice Address - Phone:239-948-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2023-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021022228122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist