Provider Demographics
NPI:1790402113
Name:PEDRINE SANTAMARIA, MAURO (DDS)
Entity type:Individual
Prefix:
First Name:MAURO
Middle Name:
Last Name:PEDRINE SANTAMARIA
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:MAURO
Other - Middle Name:PEDRINE
Other - Last Name:SANTAMARIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, MS, PHD
Mailing Address - Street 1:1095 VETERANS DR OFFICE 406B
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0305
Mailing Address - Country:US
Mailing Address - Phone:443-563-7917
Mailing Address - Fax:
Practice Address - Street 1:750 MORTON BLVD
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9469
Practice Address - Country:US
Practice Address - Phone:606-439-3557
Practice Address - Fax:606-439-1422
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10855122300000X, 1223G0001X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice