Provider Demographics
NPI:1669899621
Name:MAZIQUE, EDWARD CRAIG II (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:CRAIG
Last Name:MAZIQUE
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N CLARK ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3925 MINNESOTA AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-2662
Practice Address - Country:US
Practice Address - Phone:202-396-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD156951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program