Provider Demographics
NPI:1003941022
Name:MAZZUCCO, MARIA (DMD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:MAZZUCCO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:M
Other - Last Name:LUGAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-759-6710
Mailing Address - Fax:954-759-6767
Practice Address - Street 1:200 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-9026
Practice Address - Country:US
Practice Address - Phone:954-759-6710
Practice Address - Fax:954-759-6767
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15711122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075557500Medicaid
FL83355OtherBCBS
FL83355ZMedicare ID - Type Unspecified
FLV02237Medicare UPIN